QH GDL 443

Document Number # qh-gdl-443:2017
Operating Theatre Efficiency

Guideline
Operating Theatre Efficiency
Published by the State of Queensland (Queensland Health), January 2017
This document is licensed under a Creative Commons Attribution 3.0 Australia licence. To view a copy
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© State of Queensland (Queensland Health) 2017
You are free to copy, communicate and adapt the work, as long as you attribute the State of Queensland
(Queensland Health).
For more information contact:
Healthcare Improvement Unit, Department of Health, GPO Box 48, Brisbane QLD 4001, email
HIU@health.qld.gov.au, phone (07) 3328 9148..
An electronic version of this document is available at https://www.health.qld.gov.au/qhpolicy
Disclaimer:
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only. The State of Queensland makes no statements, representations or warranties about the accuracy,
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and costs you might incur as a result of the information being inaccurate or incomplete in any way, and for any
reason reliance was placed on such information.
Operating Theatre Efficiency – Guideline -2-

Contents
1. Summary ......................................................................................................................... 4
2. Scope .............................................................................................................................. 4
3. Guidelines........................................................................................................................ 5
3.1 Purpose............................................................................................................................. 5
3.2 Understanding Theatre Efficiency...................................................................................... 5
3.2.1 The Whole Patient Journey.................................................................................. 5
3.2.2 Defining Utilisation, Efficiency and Productivity .................................................... 7
3.3 Operating Theatre Measures and Metrics ......................................................................... 7
3.3.1 Context ................................................................................................................ 7
3.3.2 Using Measures and Metrics ............................................................................... 8
3.3.3 Description of Measures .................................................................................... 10
3.3.4 Benchmarking.................................................................................................... 13
3.3.5 Data Quality ....................................................................................................... 14
3.4 Managing Efficient Operating Theatres ........................................................................... 15
3.4.1 Operating Theatre Governance ......................................................................... 15
3.4.2 Roles, Responsibilities and Accountabilities ...................................................... 16
3.4.3 Reporting and Monitoring .................................................................................. 20
3.5 Best Practice Standards and Measures of Success ........................................................ 21
3.5.1 Theatre Planning ............................................................................................... 21
3.5.2 List Scheduling .................................................................................................. 26
3.5.3 Reducing Variation – ‘Green Lists’ / ‘Service Lists’ ............................................ 32
3.5.4 Patient-Specific Requirements and Preoperative Assessment........................... 33
3.5.5 Starting on Time ................................................................................................ 34
3.5.6 Changeover ....................................................................................................... 36
3.5.7 Finishing on Time .............................................................................................. 38
3.5.8 Standby Lists / Patients ..................................................................................... 40
3.5.9 Minimising Delays .............................................................................................. 42
3.5.10 Cancellations ..................................................................................................... 44
3.5.11 Comparative Elective Theatre Utilisation ............................................................ 48
3.5.12 Cost per Weighted Activity Unit by Diagnosis Related Group ............................. 49
3.5.13 Elective Surgery Patients Treated within Clinically Recommended Time by
Category ............................................................................................................ 49
3.6 Managing High Cost Drivers ............................................................................................ 50
4. Aboriginal and Torres Strait Islander Considerations .................................................... 51
5. Abbreviations ................................................................................................................. 52
6. References .................................................................................................................... 52
7. Appendices .................................................................................................................... 53
Appendix A: Theatre Efficiency Measures and Metrics .................................................... 54
Appendix B: Definitions ................................................................................................... 77
Appendix C: Management Committee Membership......................................................... 80

1. Summary
The Queensland Government’s, ‘My health, Queensland’s future: Advancing health 2026’ strategy
describes the challenges faced by public healthcare in Queensland, “Our population is ageing. A
growing number of Queenslanders live with chronic disease. Better clinical interventions and new
technologies offer the prospect of improved health outcomes. But health costs are rising and we need to
be smarter about how we deliver healthcare into the future.”
Further to this and in support of the need to deliver sustainable, efficient and effective services, in April
2016, the Queensland Audit Office (QAO) published the Queensland public hospital operating theatre
efficiency report 2015-16. The report concluded that, “Public hospitals can substantially improve their
theatre efficiency, both by increasing utilisation and by better managing their costs of surgery. That more
can be done within existing theatre infrastructure is indicative of the potential cost savings that can be
realised in the system.”
There were ten recommendations made in the report, including the need for the development of
standardised definitions, performance measures and targets, improving operating theatre governance,
reviewing theatre schedules and staff rosters and improving costing and coding services.
The following guidelines have been developed as a best practice guide for Hospital and Health Services
(HHSs) to understand and improve theatre efficiency, governance and operational management.
2. Scope
The guideline applies to all operating theatres in public hospitals in Queensland, referred to hereafter as
Hospital and Health Services (HHSs) including Mater Public Services.
Compliance with this guideline is not mandatory, but sound reasoning must exist for departing from the
recommended principles within the guideline.
It is recognised that there are many aspects of operating theatre efficiency and management that are not
addressed in version 1.0 of this document. As future versions of this guideline are developed over time
to stay up to date with best practice, additional influences will be addressed, including;
• Workforce standards
• Quality and safety
• Operating theatre costing
• Evidence-based scheduling
• Emergency surgery
Both the guideline and the associated measures and key performance indicators (KPI’s) are
developmental documents that will be reviewed and expanded as part of a staged implementation plan.
It is important to note that where measures and KPI’s have been described, statewide targets will not be
set for the first year of implementation. The approach to establishing targets and benchmarks will follow
a progressive, evidence-based approach whereby collection for the first 12 months will focus on
assessing relative performance to enable the Department to understand the level of variation. This will
ensure appropriate targets are set in the future with the expectation that these will be applied as stepped
improvement targets from Year 2 of the implementation plan.

3. Guidelines
3.1 Purpose
The purpose of the Queensland Health Theatre Efficiency Guideline is to provide a best practice guide
for operationally managing efficient public hospital operating theatres by:
1. Providing a minimum suite of agreed upon definitions, performance measures and targets to
support Hospital and Health Services and hospitals to manage, benchmark and improve theatre
performance;
2. Clarifying and formally communicating roles, responsibilities and accountabilities for delivering
efficient surgical services, both operationally and strategically;
3. Outlining the governance structure (e.g. Theatre Management Committee) by which public
hospitals should monitor the efficient use of theatres; and
4. Highlighting the major cost drivers of operating theatres
The primary focus of the document is planned (elective) surgery, though it is expected that some
aspects will also be relevant for unplanned (emergency) surgery.
3.2 Understanding Theatre Efficiency

3.2.1 The Whole Patient Journey
There are numerous factors within the perioperative setting that influence the efficiency of operating
theatres. Such factors extend beyond the immediate theatre environment and include the entire
continuum from planning, scheduling, pre-assessment and through to discharge. The following diagram
represents the three primary phases of the perioperative setting that contribute to the efficient and
productive use of operating theatres and associated resources.

Figure 1 Key Influences within the elective perioperative environment
• Planning
• Scheduling
• Preadmission assessment and preparation
• Patient readiness and current health status
• Patient preparation
Preoperative • Cancellations
• Starting and finishing on time

• Procedure times
• Changeover times
• Delays
• Training of new and junior surgical, anaesthetic and nursing
staff
• Equipment and consumables
Intraoperative • Emergency demand
• Unplanned returns to theatre
• Anaesthetic and operation complexity
• Recovery
• Unplanned admissions
• Bed management
Postoperative
It is imperative that operating theatres are not seen in isolation. The patient’s surgical journey is complex
and crosses many boundaries. Whilst the scope of this document does not currently address the
following factors, improving operating theatre performance must also be considered in the context of a
wider system, including:
 Quality assurance and safety processes

 Staff availability, skill mix and experience
 Theatre size and layout
 Hospital size and layout
 Patient flow and communication processes
 Culture of the theatre team/hospital
Staff morale, job satisfaction and the culture of theatre teams and hospitals play a significant part in the
success and delivery of all health services, and are crucial to the longevity of any change (Stapleton et al
2007). Thus, it is important that when undertaking change management initiatives, managers understand
and make deliberate efforts to actively engage their staff and ensure high morale is maintained. This
should, in-turn, increase the effectiveness of change processes necessary for improving theatre
efficiency on a sustainable basis.
Moreover, a patient-centred approach must be taken when developing new strategies and/or making
changes to processes and it is recommended that patient consultation and feedback, where appropriate,
should also underpin decisions around changes to aspects of perioperative care.

3.2.2 Defining Utilisation, Efficiency and Productivity
Historically, the concept of theatre efficiency has been misrepresented by the common inference that
high theatre utilisation is equivalent to efficiency. However, it is vital to understand and differentiate
between theatre utilisation, efficiency and productivity.
Theatre utilisation only reflects the amount of time a patient is in the operating theatre within a planned
session, and is not an indication of how productive that time is. Thus any analysis of utilisation must also
consider a hospital's surgical services efficiency, productivity and complexity as well as the effectiveness
of planning to maximise capacity and deliver on planned activity.
For example, two comparable operating theatres could fully utilise their available, planned ‘In OR’ time
without any delays, late starts or cancellations. Another theatre may consistently deliver more activity by
completing like procedures quicker, despite delays or late starts.
Similarly, an operating theatre could work to improve their performance by employing more staff (e.g.
additional layers of management, additional anaesthetic staff to reduce changeover times etc.) however
this may not necessarily improve efficiency nor be cost-effective.
In an Activity-Based Funding (ABF) environment, a better measure of technical efficiency for surgical
services is the cost per Weighted Activity Unit (WAU) delivered by the service. However, limitations in
how both costing and activity are able to be attributed solely to the operating theatres means that this
measure is primarily useful for monitoring the efficiency of the whole of services, and the activity
delivered across all Diagnosis Related Groups (DRGs).
Likewise, a reasonable indicator for productivity for surgical services is the WAU delivered per hour of
staffed theatre time. Again, due to limitations in apportioning activity solely to the operating theatres, this
measure is primarily useful at a whole of services level.
For the purposes of this guideline, operating theatre efficiency is defined as treating the right patients
and providing the right care, within clinically recommended timeframes, with the optimal use of the
resources required to deliver safe, quality care at or below an efficient price for the service.
3.3 Operating Theatre Measures and Metrics

3.3.1 Context
It is important to note that, currently, operating theatre efficiency as defined in section 3.2.2 cannot be
measured reliably through the use of a single indicator. There is also significant risk in misrepresenting
operating theatre performance based on one or only a few indicators. Hence, the purpose of this
document is not to prescribe an overall performance indicator but to provide an operationally meaningful
and useful guide that will assist managers to understand their business, identify root causes of
inefficiencies and drive improvement strategies.
The measures outlined in this guideline have been designed to balance what information is readily
available with what is a relevant and actionable suite of indicators to assist Hospitals and HHSs in
monitoring and managing their theatre performance. Whilst they represent a minimum recommended set
to monitor theatre efficiency, individual hospitals may seek to adopt additional indicators dependent on
local needs and circumstances.

Not all hospitals and surgical specialties have the same operating theatre performance profiles and
consideration needs to be given to individual differences including surgical complexity and case mix. For
example: short stay cataract surgery and intracranial surgery will have considerably different metrics, as
will comparing regional or remote hospitals to tertiary hospitals.
Whilst specific quality and safety indicators are not included in the scope of these guidelines, it is the
expectation that the principles of delivering safe and quality healthcare underpin all services provided by
Queensland Public Hospital and Health Services.
3.3.2 Using Measures and Metrics

Not all measures will be relevant for all stakeholders even within a HHS, and those useful at an
operational level will vary to those required at a strategic and executive level.
Hence, a range of measures across the perioperative setting have been recommended in this guideline
however they have been classified to ensure relevant stakeholders have access to the appropriate
reports to prevent being inundated with data. Some measures provide an overarching view of key
efficiency indicators (e.g. starting on time, early finishes, cancellations) whereas others provide
supporting information that can act as a subset of measures to assist with identifying root causes of
issues or changes in performance.
The following terms have been used to classify the measures according to their use:
 A reportable measure is one considered necessary to report and monitor on a regular basis
 A connecting measure is one that links operating theatre performance to the HHS Service
Agreement Key Performance Indicator for elective surgery
 A supplementary measure is one considered as not being routinely required however should be
readily available to support root cause analysis of issues

Figure 2 Classification of measures and metrics by governance group
It is also important that staff responsible and involved in delivering improvements to theatre efficiency
have regular access to a range of reports. This is vital for establishing and maintaining engaged teams
and also enables the opportunity for teams to be recognised for their achievements and/or raise
awareness of areas where further improvement is required. Access to reports on the following measures
should be available to all perioperative staff:

 Comparative Elective Theatre Utilisation
 Starting on Time
 Finishing on Time (Late Finishes)
 Finishing on Time (Early Finishes)
 Elective Preventable Cancellations on Day of Surgery
 Total Patients Treated
 Elective Surgery Patients Treated in Clinically Recommended Time by Category
 Elective Surgery Long Wait Patients
Further details regarding theatre governance are outlined in section 3.4.
3.3.3 Description of Measures

A description of each of the measures is outlined below. It is recommended that reporting and
management of such indicators should be undertaken at a specialty level (where relevant) to promote
accountability and to drive targeted improvements.
Standardised definitions are fundamental for ensuring all metrics are measured accurately and
consistently to enable reliable internal and, where applicable, external benchmarking. All relevant
definitions referenced within these guidelines can be located in Appendix B.
Table 1 Description of Measures

R = Reportable C = Connecting S = Supplementary
Measure Type Description
Cost per weighted Cost per weighted activity unit (WAU) by surgical
R
activity unit (WAU) diagnosis related groups (DRG).
Whole of
Elective Surgery
patient
Patients Treated The percentage of patients who received elective
journey
within Clinically C surgery and were treated within the clinically
Recommended recommended time for their urgency category.
Time
The percentage of how many planned elective

Unplanned sessions are closed at late notice (within 48 hours of
R
Session Closures the planned session time) of the total number of
Preoperative
planned elective sessions.
/ Waitlist
Management
The percentage of patients waiting longer than the
Elective Surgery
C clinically recommended time for their Category 1, 2 or 3
Long Wait Patients
Elective surgery.
Operating Theatre Efficiency – Guideline - 10 -

The difference between the number of patients added
Net Additions to
C to the elective surgery waiting list and the number of
Waiting List
patients removed (either treated or removed).
The percentage of Category 2 and 3 Elective Surgery

Treat In Turn C
patients treated in turn.
Alignment to
The percentage of patients whose assigned clinical
National Elective
urgency category aligns with that described in the
Surgery Urgency C
National Elective Surgery Urgency Categorisation
Categorisation
Guideline.
Guideline
The comparison between booked total case time (how

Booked versus
S the session was planned to be used) and actual total
Actual Time
case time (how the session was actually used).
Total Patients The total number of patients treated by operation type

S
Treated (elective or emergency).
A comparative measure of overall theatre utilisation

that considers the total time the operating theatre is
actually occupied by a patient in the OR and the
necessary time for changeover (by applying a nominal
changeover time) as a percentage of the planned time
for elective sessions.
This measure is designed to reconcile the differences
Comparative in reported utilisation between sessions with multiple
Elective Theatre R short cases and sessions with few long cases. It allows
Utilisation managers to focus on the root causes of low utilisation
i.e. late starts, slow turnovers and early finishes.
Intraoperative
However, it does not reflect the speed at which a
procedure is performed.
The occupied ‘In OR time’ is measured according to
the fundamental ‘Wheels in, Wheels Out’ measure.
The nominal changeover time is set at 15 minutes.
Percentage of elective sessions where the first case In

OR time is on or before the scheduled session start
time.
Starting On Time R
A late start is defined as any session where the first
case In OR time is after the scheduled session start
time.

The percentage of elective sessions where the last
case exits the OR 45 minutes or more before the
Finishing On Time
scheduled session end time.
– Underruns R
(Early Finishes) An early finish is defined as any session where the last
case exits the OR greater than 45 minutes before the
The percentage of elective sessions where the last
case exits the OR 30 minutes or more after the
Finishing On Time scheduled session end time.
– Overruns R
(Late Finishes) A late finish is defined as any session where the last
case exits the OR greater than 30 minutes after the
Elective The proportion of patients booked into elective

Preventable Day sessions who are cancelled on the day of surgery for
R
of Surgery selected preventable cancellation reason codes (See
Cancellations Appendix A).
The average time between all cases treated in elective

Average
S sessions measured from previous case ‘Out OR’ to
Changeover Time
next case ‘In OR’.
Elective The percentage of all elective patients cancelled on the

Cancellations on S day of surgery for both hospital and patient initiated
Day of Surgery reasons.
Average Elective
The average time from ‘In Anaesthetic’ to ‘Procedure
Pre-Procedure
S Start’ for the first case of an elective morning or all day
Anaesthetic Care
session.
Time
Of those lists starting late, the average time (minutes)

Average Late Start by which they started late. A late start is defined as any
S
minutes session where the first case In OR time is after the
scheduled session start time.
The total delays (in minutes) resulting from late starts

Elective Delay (first case In OR time is after the scheduled session
S
minutes start time) and prolonged changeover times (change
over time >15 minutes).
Postoperative Average Recovery

Delay between The average time taken between when an elective
ready for S patient is ready for discharge to when they are actually
discharge to discharged.
discharge

Impact of
Emergency A measure of ‘In Operating Room’ use that reflects how
Surgery much time the operating theatre is occupied by a
Emergency patient as a percentage of the planned time for
Theatre R emergency surgery sessions.
Occupancy
This is measured according to the fundamental
‘Wheels in, Wheels Out’ measure.
Emergency Cases
Percentage of planned Elective session time occupied
in Elective S
by Emergency cases.
Sessions
Emergency case minutes performed out of session (i.e.

Out of Session
not within a planned session) as a percentage of the
Emergency Case S
total emergency case minutes completed by category
Time
A - E.
Other metrics which may be useful for HHSs to consider include:
• Proportion of Eligible Day/Extended Day/Day of Surgery Admission cases that were treated as
Day/Extended Day/Day of Surgery Admission cases
• Unplanned Admissions
• Unplanned returns to theatre (in relation to the effect on available theatre time and productivity,
as opposed to quality and safety)
3.3.4 Benchmarking
Benchmarking should only be undertaken between peer hospitals, taking into account:
• Case mix
• Training requirements
• Physical layout (e.g. anaesthetic bays)
• Volume of elective and emergency surgery patients
• Facility capability according to the Queensland Clinical Services Capability Framework
As a guide, peer hospital groupings are recommended according to acute hospital category and
remoteness as per The Australian Institute of Health and Welfare (AIHW) revised peer groups, published
on the AIHW website. Hospitals grouped under both the same acute hospital category and by the
same/similar remoteness area classification could be considered peer hospitals for benchmarking
purposes. However, it is important to note that variations based on the above list of factors may still exist
between these groupings of peer hospitals and thus further consideration to such differences should also
be taken into account.

3.3.5 Data Quality
The significance of data integrity and quality must not be underestimated within the context of quality
improvement. Whilst it is acknowledged that variation in process may exist, it is crucial that
standardisation of data entry and the application of prescribed definitions to each of the data elements
and time stamps remain consistent. This is to ensure comparable and reliable benchmarking as well as
best practice clinical record-keeping.
To ensure data integrity and consistency, it is recommended that HHSs:

 Ensure staff are provided adequate and ongoing training in the use and application of the relevant
operating room management information systems, including an understanding of how the data is
used and the impacts of poor data quality
 Ensure access controls are in place, including approval and verification processes for new users to
ensure appropriate levels of access are assigned
 Maintain an up-to-date access and training register for all relevant staff
 Develop and make readily available orientation and desktop manuals for the use and application of
operating room management information systems
 Display cheat sheets at theatre work stations that draw attention to important data entry instructions
as well as ensure access to time stamp definitions for quick reference
 Regularly audit data entry for accuracy, completeness and timeliness
 Regularly audit user access and remove access for staff where no longer required

3.4 Managing Efficient Operating Theatres
3.4.1 Operating Theatre Governance
As previously noted, improving operating theatre efficiency must be seen in the context of a wider and
interdependent system where the upstream and downstream impacts of each part of the patient journey
(from preoperative assessment through to discharge) are reviewed holistically. Consequently, any efforts
to improve efficiency should involve a number of departments across multiple disciplines to ensure high-
quality, cost-effective and safe care.
It is recommended that HHSs establish structured governance teams / committees at both an
operational and strategic level, focusing on collaborative and interdisciplinary leadership.
Theatre Scheduling Committee/Team (Operational Management)

Incorporates all aspects of the patient journey, from pre-admission to discharge. Responsible for:
 Day-to-day planning, management and operations of operating theatres at the hospital level
 Review, planning and preparation for theatre lists for the following two weeks
 Review of schedules, surgeon allocations and rostering for the following 6 weeks
 Review and monitoring of all operational indicators and measures (as per section 3.3.2)
 Implementing improvement initiatives
 Escalating any risks and issues to the Strategic Management Committee/Team
It is recommended that this committee meet weekly (or as required)
Theatre Management Committee/Team (Strategic Management)

Incorporates representatives from hospitals within a HHS or hospital network. Responsible for:
 The strategic oversight, management, productivity and efficiency of operating theatres whilst ensuring
quality of patient care is not compromised
 Monitoring strategic indicators and measures (as per section 3.3.2) and addressing any performance
issues
 Monitoring and managing emergency and non-surgical procedure demand on operating theatres
 Planning and setting the master theatre template and approving any changes to ensure funded
capacity is appropriately allocated to align demand and supply
 Reviewing waiting lists against specialty and surgeon allocations within the master theatre template to
efficiently service waiting lists
 Planning for closures or periods of reduced activity (e.g. Christmas, public holidays, planned
maintenance etc.)
 Risk management and incident reporting
 Policy and protocol development and revision
It is recommended that this committee meet monthly (or as required)

Recommended core and co-opted members are further outlined in Appendix C.
The following principles are important for the effective governance of operating theatres and should be
adopted when establishing any teams, committees and/or sub committees:
 Theatre Management teams and committees require strong leadership, appropriate membership and
the authority to take action
 Information about theatre performance should be easily accessible and available on a regular basis
and should be used to drive change and improvements
 There is clear communication and co-ordination between all craft groups including managers,
surgeons, anaesthetists, theatres, preoperative assessment, wards and bed managers
It should be noted that existing governance frameworks and structures, particularly for quality and safety,
should be combined with the recommended theatre efficiency governance structure to reduce
administrative burden where possible.
3.4.2 Roles, Responsibilities and Accountabilities

In addition to needing overarching management teams/committees to review, monitor and manage
theatre performance, the delegation of specific responsibilities to nominated accountable officers is also
necessary to ensure the day-to-day running of the operating theatre suite is efficient and effective.
It is recommended that within each hospital, operational theatre management roles are clearly assigned
to appropriate, accountable positions within the operating theatre. Delegations may vary across
hospitals, though ultimately, responsibilities should be assigned to the most senior officer or appropriate
delegate where possible. In smaller regional or rural facilities, some positions may be required to fulfil
multiple roles and/or responsibilities.
It is important that accountable officers are aware of their responsibilities and contribution to improving
theatre efficiency. The following table outlines the minimum responsibilities that should be assigned for
the monitoring and improvement of theatre efficiency:
Head of Operating Theatres - Responsibilities

Nursing Medical - Surgery Medical - Anaesthetics
 Overall management of budget  Take an active governance role in  Take an active governance role
and resources within the theatre management to ensure that in theatre management to
perioperative service the surgical care provided is patient ensure the anaesthetic care
centred provided is patient centred
 Ensure appropriate nursing
workforce availability for the  Ensure appropriate surgical  Ensure appropriate anaesthetic
perioperative environment workforce availability for the workforce availability for the
perioperative environment perioperative environment
 Review and monitor surgical (including pre-admission,
services in collaboration with  Review and monitor services in theatre, and postoperative
relevant stakeholders to achieve collaboration with relevant care)
performance benchmarks stakeholders to achieve
performance benchmarks  Review and monitor services in
 Foster collaborative teamwork collaboration with relevant
to drive continuous stakeholders to achieve
improvement performance benchmarks

 Review and analyse service  Advocate and liaise with hospital  Advocate and liaise with
activity and resource allocations administration to ensure services hospital administration to
to assist capacity planning for are adequately staffed and equipped ensure services are provided in
future service provision to provide a safe, efficient and a safe, efficient and effective
effective working environment working environment
 Coordinate the capital
equipment list and collaborate in  Ensure that processes and protocols  Provide advice and direction
the prioritisation and negotiation are in place that reflect best practice regarding issues relating to
for equipment in the operating theatre environment anaesthesia and sedation
governance
 Provide mentorship and support  Ensure that a professional and
to the professional development respectful work environment is  Provide feedback to the
of the nursing staff within maintained department of anaesthetics
perioperative services regarding perioperative issues
 Provide feedback to all surgical of importance
 Actively celebrate successes departments regarding perioperative
and encourage high performers issues of importance  Actively celebrate successes
and encourage high performers
 Address root causes of poor  Actively celebrate successes and
performance encourage high performers  Address root causes of poor
performance
 Promote quality activities and  Address root causes of poor
coordinate quality improvement performance  Ensure audit processes are in
projects within the department place to monitor and assess
 Ensure audit processes are in place key quality and safety practices
to monitor and assess key quality
and safety practices
Floor / Duty Coordinator - Responsibilities
Nursing Medical - Surgery Medical - Anaesthetics

 Ensure the daily provision of an  Be available on-site and contactable  Be available on-site and
appropriate and safe standard during the working day to assist with contactable during the working
of clinical care providing advice and/or resolving day to trouble-shoot issues
clinical issues relating to preoperative
 Daily coordination of the preparation, list management
efficient use of emergency and  Resolve problems relating to urgent and postoperative care
elective operating sessions in operating room access for acute
collaboration with the Elective care patients  Work collaboratively with the
Surgery Coordinator, multi-disciplinary health care
Anaesthetic Department,  Promote “peer to peer” professionals and consumers to
Surgeons, and Perioperative communication and collaboration in effectively and efficiently
Nursing Unit Managers, Bed time-critical decision making relating manage emergency surgery
Managers and ancillary staff to theatre access
 Work collaboratively with
 Work collaboratively with multi-  Take steps to ensure that potential anaesthetic, nursing and
disciplinary health care problems of resource availability can surgery staff to reduce late
professionals and consumers to be predicted and resolved in a pre- starts and cancellations on the
effectively and efficiently emptive fashion day of surgery
manage emergency surgery,  Take on a leadership role when  Ensure that all decisions made
reduce impacts on elective there is disagreement amongst craft
surgery and maintain a patient are patient centred
groups without prejudice
centred focus

 Ensure resources (including  Work collaboratively with surgical,  Ensure that the operating
staffing) and equipment are nursing and anaesthetic staff to environment is being used
allocated effectively and reduce late starts and cancellations effectively and efficiently
efficiently and are ready and on the day of surgery
available for all cases each day  Ensure that a professional work
to minimise delays  Ensure that all decisions made are environment is maintained
patient centred
 Liaise with surgical and
 Ensure that the operating
anaesthetic leads to resolve
environment is being used
issues relating to access to
effectively and efficiently
emergency theatre time
 Ensure that a professional work
 Identify and escalate possible environment is maintained
late starts and cancellations on
the day of surgery via local
escalation pathways
 Coordinate meal relief to
minimise interruptions and
delays to theatre lists
 Assist in achieving
perioperative service and
organisational performance
benchmarks and elective and
emergency surgery KPI’s
 Provide leadership, mentorship
and support to perioperative
service staff
Other key roles within the context of managing theatre efficiency:

Role Responsibilities
Elective Surgery  Proactively monitor waiting lists and theatre supply and escalate demand and
Coordinator / capacity issues to operational and strategic management committees to inform
Clinical Care theatre template planning and session allocations
Coordinator  Ensure data entry for theatre bookings is consistent and accurate
 Monitor and provide expert advice on best practice management of elective surgery
waiting lists to ensure treatment within clinically recommended timeframes
 Monitor and improve waitlist management measures. E.g. treat in turn and alignment
to the NESUCG
 Orientate new staff on elective surgery referral and bookings processes
 Monitor the booked vs actual indicator to ensure booking practices maximise
available theatre time and provide advice to drive improvements
 Monitor cancellation rates for failure to attend to ensure booking confirmation
processes are effective

Data Manager  Responsible for the coordination, support, enhancement and ongoing management
of data and data sets within the operating room management information system,
including inventories for prosthetics and high cost consumables
 Produce standard reports for both operational and strategic purposes, including
weekly performance reports and reports on data quality, providing information for
analysis and publication as required
 Actively participate in the development and tracking of performance indicators
 Provide education and training to staff to ensure consistency and accuracy in the
application of codes, time stamp definitions and data entry
 Provide expert advice and support in data management as well as coordinate the
dissemination of changes to processes
 Coordinate ongoing systems management, development, testing and
implementation of changes
Pre-admission  Coordinate, manage and review pre-admission processes to ensure services are
Manager effective in optimising the patients fitness and readiness for surgery
 Provide expert advice on best practice standards when reviewing models of care for
pre-assessment
 Review and monitor cancellations relating to pre-admission processes, for example:
unfit due to condition or preparation, no longer requires treatment
Admissions  Coordinate, manage and review the admission process for patients to ensure
Manager effective patient flow where patients are processed and ready for surgery without
delay
 Review admission times to ensure they enable timely access to theatre
 Manage and review delays, ensuring any anticipated delays are communicated to
patients to keep them informed about their journey
 Monitor cancellation rates for ‘patient did not wait’ to ensure admissions processes
are patient focused and appropriate

3.4.3 Reporting and Monitoring
The following principles should underpin all reporting and monitoring of theatre efficiency:
 Reports should be easily accessible, relatable and easy to understand
 Reports need to provide meaningful information that can be used to drive change
 Reports should be provided in a timely manner that allows sufficient time to review prior to
management meetings
 All members of the management committee / team have a responsibility to attend meetings prepared,
having pre-read the available reports and actively participate in developing improvement initiatives
 Actions arising from theatre management meetings should be recorded on a register with responsible
persons and timeframes assigned and revisited then closed, as required, at future meetings
 Reports and data should be visible and available to staff responsible for and involved in the delivery
of services
 Performance issues should be addressed and escalated via the theatre management committees /
teams
 Data collections and reports should be generated via a dedicated data manager and custodian to
ensure consistency in reporting
 Regular auditing, training and education with staff to ensure accuracy and reliability of data should be
undertaken

3.5 Best Practice Standards and Measures of Success
As discussed in section 3.2.1, there are numerous internal and external factors within the perioperative
setting that influence the efficiency of operating theatres from planning and scheduling, pre-assessment,
through to patient discharge. This section of the guideline is focused on linking the suggested measures
and metrics to a range of best practice standards intended to assist HHSs with optimising efficiency
across the surgery continuum under the key areas:
 Theatre planning
 List scheduling
 Patient specific requirements and preoperative assessment
 Starting on time
 Changeover time
 Finishing on time
 Minimising delays
 Cancellations
It is acknowledged that sound reasoning may exist for appropriate variation in the application of some of
the best practice guidelines in different facilities and Hospital and Health services due to specific
circumstances. Where such variation exists, facilities should have clearly documented processes that
retain similar principles to those outlined and ensure comparable and reliable data is able to be provided.
Considerations for measures that do not fit specifically within one of these areas e.g. Comparative
Theatre Utilisation and cost per weighted activity unit are discussed further in sections 3.5.11 and 3.5.12.
3.5.1 Theatre Planning

The effectiveness of HHSs in delivering efficient surgical services that align supply with demand is
dependent on a solid understanding of the capacity of their hospitals, combined with well-established
planning processes that ensure maximum utilisation of all resources.
This utilisation of hospital resources constitutes a major contributing factor to the operating costs of a
hospital and, as such, poor coordination and planning can result in significant waste and inefficiencies.
It is necessary that HHSs engage in thorough planning processes that focus on the following key
elements:
 Conduct regular reviews and analysis of demand to ensure the appropriate allocation of resources
and funded sessions
 An annual (at minimum) review and consolidation of a master template outlining the number of
required and funded theatre sessions. The master template may be established on a weekly,
fortnightly or other cyclical basis (a common approach is a four weekly template) but in principle
should represent the number of sessions a theatre is funded to run on a routine basis

 Agreement on planned closures for each year to determine how many weeks of the year theatres are
planned to operate
 Robust planning and coordination processes that enable flexibility between the allocation of theatre
sessions such that elective, trauma and emergency theatre time allocation is responsive to changing
demand and case mix at specialty and consultant level
 Scheduling and booking processes that enable early identification of a misalignment between
demand and capacity so that this can be addressed through the reallocation of sessions as required
 Communication processes that ensure key stakeholders have access to planning documentation and
are notified of changes as they arise, from the Master Template through to daily theatre lists
The following timeline represents a sound approach to planning elective surgery to support the delivery
of the above:
Figure 3 Elective Surgery Planning

Hospitals without dedicated emergency theatres and those smaller hospitals reliant on a Visiting Medical
Officer (VMO) workforce may consider revising the above timeframes based on specific service
requirements. For example, hospitals without emergency theatres may elect to partially book lists greater
than 2 weeks and adopt a ‘standby patient’ strategy to fill lists where there is a lack of emergency
demand.
In addition to the above, it is also important that strong governance over leave management, template
and/or list changes is established via means of:
 Business rules regarding leave approval with a minimum 6 weeks’ notice for all staff
 Local escalation policy for approving cancellations on the day of surgery
 Centrally located master theatre template, weekly timetable and draft daily theatre lists for access by
all relevant staff
 A dedicated custodian of the Master Theatre templates responsible for the coordination and approval
of changes. It is recommended that the Elective Surgery Coordinator (or equivalent) undertakes this
function to maintain oversight of waiting list demand and supply in liaison with the Theatre
Management committees / teams
 Clear policies and procedures for reallocating and/or cancelling or changing lists and disseminating
information to all stakeholders. It is recommended that:
- Requests for permanent / semi-permanent changes to the Master Template are made and
endorsed via the Theatre Management committee / team
- Requests for ad-hoc changes to session allocations are made and approved via the Theatre
Scheduling committee / team
- Requests for changes to theatre lists within 2 weeks should be escalated via the Theatre
Scheduling committee / team (or delegate as per local policy)
- Requests for changes to theatre lists within 1 week should be escalated via the Theatre
Scheduling committee, or if insufficient time, to Specialty Director (or delegate as per local policy)
- Requests for changes to theatre lists within 48 hours should be escalated to the Head of Theatre
and Theatre Floor Coordinator (or delegate as per local policy)
Hospital and Health Services should also give careful consideration to the planning and management of
emergency surgery and non-surgical procedures so that demand for such activity is appropriately
accommodated to reduce impacts on elective sessions. Provisions for these services will be dependent
on individual hospital demand, workforce and resources. HHSs should adopt the principles outlined in
the Queensland Health Emergency Surgery Access Guideline for the management of emergency
surgery.

Measure(s) of Success
Measure Use and Considerations Qualitative Assessment
 To be reviewed in conjunction with

comparative elective theatre utilisation
as a session may be occupied however  What protocols are in place to ensure
poorly utilised. For example: Unplanned vacant sessions within the template are
session closures may be 0% (i.e. every covered and used?
Unplanned planned session has had 1 or more
Session patients treated) however utilisation is  Are planned closures communicated to
Closures only 20% overall, thus broadly key stakeholders in a timely manner?
inefficient  Are session closures being
 An all-day session is reported as one appropriately recorded in the operating
session, hence it is recommended that theatre management system?
HHSs report on unplanned closures by
session type
 To be reviewed in conjunction with

other emergency surgery measures for
a balanced perspective
 Primarily to be used to inform the need
for increasing or decreasing planned
 Is the majority of the emergency
emergency sessions
caseload being performed in session?
 This measure does not enable
Emergency  What proportion of emergency surgery
delineation between low utilisation due
Theatre workload is Orthopaedics? If > 50%
to no emergency demand and low
Occupancy has consideration been given to a
utilisation due to inefficiencies and
dedicated orthopaedic emergency
should be considered in conjunction
theatre? (As per the Emergency
with out-of-session emergency activity
Surgery Access Guideline)
 Occupancy may be generally lower due
to emergency cases being of typically
higher acuity and complexity which may
also increase changeover times and
delays
 What are the main specialties occupying

 This measure may be used when elective sessions for emergency
considering demand for emergency workload?
Emergency
surgery and the need for new /
Cases in Elective
additional dedicated emergency or  If >30% for Orthopaedics, has
Sessions consideration been given to a dedicated
trauma sessions
orthopaedic theatre (As per the
Emergency Surgery Access Guideline)

 Are emergency cases being managed in
 It is recommended that a review of the accordance with the Emergency Surgery
categorisation and breach times of Access Guideline?
Out of Session
emergency patients treated out of  Are any Category C - E emergency
session is monitored to identify if cases cases treated out of session?
Emergency Case
Time are being performed out of session as a  If ≥ 30% of emergency cases run over
result of true demand or because there 2200hrs, has consideration been given to
has been insufficient capacity to a dedicated emergency theatre? (as per
provide surgery in-session the Emergency Surgery Access
Guideline)
 A productivity measure to monitor

overall throughput
 It is recommended that HHSs monitor  Are variations in caseload the result of
this on a monthly basis and at a
known and planned changes in activity or
specialty level is it the result of unexpected events?
Total Patients  Variation in total patients treated may  Has there been any significant change in
Treated be the result of a range of factors which
cancellation rates, patient acuity and/or
should be considered, including:
other efficiency measures that may have
- Change in the number of operating contributed to an increase or decrease in
sessions undertaken
throughout and supply?
- Improvements or decline in
efficiency performance
- Case mix and acuity of patients
 Best reviewed at a specialty level

 A positive value should result in a  Has there been a change in demand
(additions to the waiting list) and why?
growth in the waiting list (i.e. more
patients added than removed)  Is this due to an increase in outpatient
activity?
 A negative value should result in a
reduction in the waiting list (i.e. more  Has there been a change in removal
patients removed than added) rates and are patients being
appropriately referred for surgery?
Net Additions to  A consistently positive or negative
waiting list value may indicate the need for a  Has there been a change in the number
review and realignment of session of patients treated and why?
allocations between specialties  Are there any short to mid-term
 When using this data for sustainability significant trends that may require a
reviews, careful consideration to review of session allocations?
removals as a result of outsourcing  Are there any long term significant trends
must be accounted for, particularly if that may require a review of the master
outsourcing is not anticipated to form theatre template?
future core business

3.5.2 List Scheduling
Principles
Effective theatre scheduling is fundamental to optimising the use of available theatre time and increasing
throughput with the main aspects of scheduling falling into one of three phases:
1. Theatre List Planning
2. Theatre List Bookings
3. Ordering Theatre Lists
1) Theatre List Planning:
It is recommended that, where possible:

 Same surgeon, all-day lists should be maximised as opposed to split morning and afternoon sessions
 Where same surgeon, all-day lists are not possible, same specialty, all day lists should be prioritised
 Meal relief should be rostered to enable continuity and flow to maximise utilisation and productivity.
Where meal relief is not rostered, the following should be considered in the context of reporting on
efficiency:
- Average Changeover time: For all-day lists, Comparative Theatre Utilisation will not be
affected, however average changeover time will be protracted due to vacant In OR time during
the meal break period
- Comparative Theatre Utilisation: Where split sessions (morning and afternoon) are rostered,
early finishes and overruns in the morning session and late starts for an afternoon session will
negatively impact Comparative Theatre Utilisation
2) Theatre List Bookings:
The ultimate goal for booking lists is to consistently align planned utilisation to actual utilisation. Accurate
and reliable booking processes can significantly improve finishing on time by not under-booking or over-
booking lists and reducing cancellations on the day of surgery as a result of insufficient theatre time.
It is fundamental that hospitals have a good understanding of anaesthetic time (pre and post procedure),
procedure time and changeover time to ensure effectiveness of bookings. The following diagram
represents the stages of intraoperative time that should be considered when allocating bookings:

Figure 4 Intraoperative time considerations for scheduling cases
Whilst optimally the pre and post procedure times in OR will be minimal, hospitals should review and
consider the time occupied by these phases when estimating overall case times.
There are various factors which can influence the duration of the pre and post procedure times within the
OR including the type of surgery (e.g. Caesarean sections requiring a TAP block post procedure will
require increased time from Procedure finish to Out OR) and whether or not an anaesthetic room and
staff are available.
If an anaesthetic room and staff are available to permit the commencement of anaesthetic care of one
patient before the completion of anaesthetic care of another patient for the same operating theatre, then
the pre procedure time within the OR is going to be considerably less than those where anaesthetic
preparation is required In OR. It should also be noted that hospitals undertaking parallel processing of
patients may report an inflated pre-procedure anaesthetic time, hence review of this average time should
only be measured using the first case of an elective morning or all day session.
The following is recommended for booking and estimating case times to plan theatre lists:
 HHS’s should establish clear procedures for compiling theatre lists including key role responsibilities
(surgeon/anaesthetist, theatre, booking office etc.), how information should be communicated to key
areas, timeframes for distribution and processes for notifying of changes
 Estimated Case Time = Average Procedure Time + Average Changeover time noting the following
considerations:
- Individual consideration regarding pre and post procedure time (typically relevant to anaesthetic
time in the OR) should be applied when estimating total case time
- The average procedure time used should be as per the theatre management system’s generated
average procedure time based on applicable procedure codes (measured from ‘Procedure Start’
to ‘Procedure Finish’), unless indicated otherwise by the treating surgeon on the booking form
- The benchmark for average changeover time is 15 minutes however, when applying this
measure, consideration should be given to case mix, availability of an anaesthetic room and the
impact of emergency surgery performed in elective lists
- Patients requiring complex anaesthetic and / or other preparation (e.g. BMI > 40) should be
allocated additional time. This information needs to be communicated to the Booking Office at
time of referral to the waiting list and / or immediately following pre-anaesthetic assessment

3) Ordering Theatre Lists:
Appropriate ordering of a theatre list can reduce intraoperative delays and contribute to improved
changeover times, patient flow and bed access. Notwithstanding individual patient needs, clinical
discretion or hospital specific arrangements, the following principles for the ordering of patients on a list
are recommended:
Figure 5 List Order Priorities
Other Considerations for ordering of lists:

 Day of surgery admissions should avoid being booked as the first case on a morning list to allow time
for discharges and confirmation of bed availability
 Extended day of surgery (23 hour ward patients) should be booked later on the list to minimise bed
occupancy
 A patient’s place of residence should be considered, particularly for rural patients e.g. rural patients to
be mid-morning to enable sufficient time to arrive and return home within daylight hours
 Patients requiring certain pathology should be booked to allow sufficient time for the transportation of
specimens for timely processing
 ICU bed availability

 Availability of support services (e.g. medical imaging interpreter services, renal dialysis)
 Equipment, prosthetic and product representative availability
 Individual patient requirements (e.g. mental health, security, special needs)
 Patient allergies (e.g. Latex)
In line with the recommended planning and review timeline as per section 3.5.1, the final list order
should undergo clinical consultation.
 To be used for planning and rostering

purposes to enable starting on time
 How is this measure being used to
 HHSs may elect to develop reports that inform bookings practices and
drill down to specialty, procedural and / or estimated case times?
consultant level as required
 What processes are in place to
Average  Average times may include delays regularly review Pre-Procedure
Elective Pre- between ‘In Anaesthetic’ to ‘Procedure Anaesthetic Care Time to better align
Procedure Start’ which may not necessarily be related
Anaesthetic booked versus actual utilisation
to anaesthetic inefficiencies
Care Time  For hospitals commencing
 HHSs that commence anaesthetic outside anaesthetic outside the OR, what is
the OR must ensure robust processes are the process for communicating and
in place to communicate and record the recording accurate ‘In Anaesthetic’
accurate ‘In Anaesthetic’ time as this may time?
not be visible to the staff in the OR who
are responsible for the data entry
 Used to inform bookings processes to

enable a more accurate estimate of  How is this measure being used to
changeover times inform bookings practices and list
scheduling?
 Case mix should be considered when
comparing average changeover times as  What processes are in place to
Average more complex cases may require longer regularly review changeover times to
Changeover set-up and anaesthetic preparation thus inform booking and scheduling
Time increasing changeover time practices?
 Where patients are treated in a different  How are meal breaks rostered and is
theatre to that which they were booked, this contributing to reportable
despite being treated by the same team, protracted changeover times?
the time for that case will be reflected as
an extended changeover for that session

 Hospitals running all day lists without meal
relief need to consider that average
changeover times will be impacted as the
time taken for meal breaks will be reflected
as changeover time
 Changeover time will typically be higher
where emergency cases are completed in
elective sessions, hence this indicator
should also be considered against the
indicator for emergency cases in elective
sessions
 It is recommended that hospitals report on
this measure with the option to drill down
to specialty / sub-specialty level and / or
 Regular and significant variation between

booked utilisation and actual utilisation
may indicate the need for a review of
booking and scheduling processes to
ensure estimated times are aligned with
actual operating times. However, this
needs to be considered holistically to  Are ‘underrun’ lists the result of
ensure bookings practices are not cancellations on the day of surgery or
changed to accommodate inefficient the result of an under-booked list?
practices  Are ‘overrun’ lists the result of late
Booked versus
Actual Time  Reliability of this measure is dependent on starts, delays and/or protracted
the accurate data entry of estimated case changeovers or due to over-booked
times. Booking systems that use a points lists?
and / or other non-time specific process  How is this report used to inform
may not accurately record planned booking and scheduling practices?
utilisation unless estimated times are
updated in the system
 Data on total booked elective minutes
should be snapshotted no earlier than
close of business the day prior but before
any day of surgery cancellations
 It is recommended that HHSs report on  Is the hospital’s admission times protocol

Elective
cancellations by cancellation reason code appropriate and reasonable in terms of
Cancellations
to review the proportion of hospital and patient waiting times?
on Day of
Surgery patient initiated cancellations as well as  What is the hospital’s policy / procedure
preventable cancellations on elective surgery bed quotas?

 Cancellation reasons relevant to list  Does the quota on bed bookings
scheduling may include: consider seasonal trends?
 Patient did not wait  What is the escalation and management
 No beds procedure for anticipated list overruns?
 No ICU beds  How are lists reviewed and ordered to

ensure availability of equipment/
 No operating theatre time
prosthesis/ resources?
 Equipment unavailable

3.5.3 Reducing Variation – ‘Green Lists’ / ‘Service Lists’
One approach to list planning and scheduling which HHS’s may consider is that of ‘Service Lists’ or
‘Green Lists.’ Whilst not practical for all sessions and hospitals, the purpose of these models
is to increase efficiency and productivity by reducing variation.
Background:
The Green List is a model adopted in the National Health Service (NHS), United Kingdom and aims at
increasing predictability and streamlining based on the concept of repetition and use of ‘Lean Thinking’
principles. The ‘Service List’ model forms part of the ‘The Productive Operating Theatre’ (TPOT)
program and is based on the ‘Green List’ model, with the primary focus of using consistent teams for
dedicated non-training lists.
Whilst training and education of staff is recognised as being fundamental to the delivery of sustainable,
safe and quality services, these models offer opportunities to consolidate efficient processes and
maximise patient throughput. Furthermore, Green lists may be used to offset any increased
requirements for training so that overall supply is maintained.
Principles:
 Increase efficiency and productivity within existing resources
 Consistent teams, case mix, equipment, and session times will cultivate familiarity to increase
knowledge and speed
 Appropriate patient selection and preoperative assessment are pivotal for the effectiveness and
safety of these lists
 Regular review of lists is fundamental to improving future processes and developing sustainable,
efficient practices
List Characteristics:
 Same number and type of cases
 Agreed anaesthetic and surgery times
 Start, finish and break times are agreed in advance
 Consistent theatre team (surgeon, anaesthetist, theatre nurses etc.)
 No (or very minimal) opportunities for training
 Lists are planned and confirmed well in advance (3 weeks)
 Selected patients have undergone necessary preoperative and pre-anaesthetic preparation
 List order is set prior to day of surgery and is not changed
 All patients are admitted on the day of surgery
 A team debrief is undertaken at the end of each list to reflect and report any issues to the theatre
management committee for further review
 Equipment is readily available for high turnover lists

3.5.4 Patient-Specific Requirements and Preoperative Assessment
The smooth and effective running of a theatre on the day of surgery is significantly enhanced through
thorough planning and preparation of both the operating theatre and the patient.
As such, a preoperative assessment of the patient should be undertaken that: establishes that the
patient is fully informed and wishes to undergo the procedure; supports optimising the patient’s fitness
for the surgery and anaesthetic; and minimises the risk of late cancellations by ensuring that all essential
resources and discharge requirements are identified in advance.
It is recommended that HHSs:
 Ensure appropriate pre-anaesthetic and preoperative assessment processes are in place that
adequately prepare patients for surgery and identify any resource and / or discharge requirements in
advance
 Have clear processes for the documentation and communication of specific preoperative information
to booking officers and theatre
As per Queensland Health’s Elective Surgery Implementation Standard, preadmission assessment
should be completed at least six weeks in advance of the expected date of surgery for category 2 and 3
patients, and at least seven days prior to surgery for category 1 patients.
The preoperative assessment service offered by hospitals should be dependent on the type of surgery
and the clinical needs of the patient. For example, regional or rural hospitals may choose to offer
preadmission services using telehealth, while some patients may be eligible for nurse-led pre-admission
assessments.
Some models of preoperative assessments are multidisciplinary and include pharmacists and other
allied health professionals.
 Cancellation reasons relevant to  What is the hospital’s process for

preoperative assessment and work-up confirming surgery to prevent last-
may include: minute cancellations and is it effective?
- Patient cancelled booking  Is the pre-op education material and
Elective - Unfit due to condition information provided to patients
Cancellations on adequate and appropriate for preparing
- Unfit due to preparation
Day of Surgery patients for surgery?
- Failed to attend day of surgery
 Does the hospital have a robust and
- No longer requires treatment effective auditing process to ensure
- Patient requested to be removed patient details and waiting lists remain
- Treated elsewhere up-to-date?

3.5.5 Starting on Time
One of the key contributors to improving theatre efficiency is starting on time. Starting a list on time and
as planned will ensure the greatest opportunity to finish on time (and thus minimise overtime costs),
avoid unnecessary cancellations and maximise the use of available theatre time to increase productivity.
An on-time start is measured by the difference between the session start time and first case In OR time,
such that the first patient enters the OR either before or on the scheduled session start time.
There are a number of factors which can contribute to a list starting late including:
 Patient arriving late or not prepared (e.g. incorrect fasting)
 Patient not prepared by the hospital in time (e.g. due to orderly being unavailable, ward failing to have
patient ready for transfer, bottleneck in admissions)
 Change to list order on the day of surgery
 Incomplete documentation (e.g. consent)
 Equipment / theatre unavailable
 Staff unavailable / late
 Unexpected complex anaesthetic preparation
 Previous list over running (for afternoon sessions)
 Emergency / priority cases
 Delayed anaesthetic assessment on admission
The following recommendations are intended to increase the likelihood of lists starting on time.
HHSs should ensure they have:
 Implemented reliable confirmation processes for patients at least the day before surgery to confirm
admission details including time, location (where to go), what to bring and fasting instructions
 Communicated and displayed clearly defined timeframes for staff relating to key stages of the patient
journey from patient arrival to In OR
 Standardised day of surgery admission processes to maximise patient flow including:
- Clearly defined protocols for allocating admission times for patients (e.g. minimum 90 minutes prior
to planned In OR time)
- Use of staggered admission times to prevent bottlenecks and delays
- A single point of admission
- Pre-assembled and pre-prepared paperwork
- Processes for the early identification of eligible day of surgery and extended day of surgery
patients
- Processes for flagging and communicating details of patients requiring longer anaesthetic
preparation (including anaesthetic assessment on admission) and arrangements made to
commence preparations early, which may also require the review of rosters for all professional
streams to enable the first case to start on time

 Clear escalation pathways for proactively flagging potential late starts (further details regarding roles
and responsibilities are outlined in Section 3.4.2)
 Processes in place for Theatre Managers to review lists the afternoon prior to ensure all necessary
equipment and resources will be available and ready to commence cases on-time
 Readily accessible, up-to-date theatre lists for all relevant stakeholders (including consultant and
junior surgical staff, anaesthetic staff, nursing staff and support services)
 Processes for recording all late starts in the operating theatre management system, with the
appropriate delay reason code entered
 It is recommended that hospitals report  Are admission times appropriate so that

on this measure by session type there is sufficient time to prepare the
(morning, afternoon and all day sessions) patient for an on-time start?
to understand the impacts that morning
 Are there trends across certain
overruns have on afternoon on-time
specialties?
starts
 Are there rostering issues such that other
 If morning sessions regularly overrun, the
commitments are preventing availability
starting on time result will continue to be
of staff to start on time (e.g. ward rounds,
negatively impacted as this will delay the
clinics running late)?
start of afternoon sessions scheduled for
Starting on
the same theatre  What is the hospital’s process for
Time flagging and communicating difficult
 For this metric to be most useful, HHSs
patients who require complex
should focus on establishing processes
anaesthetic preparation or positioning?
and systems to ensure the reasons for
delays are consistently recorded which  What is the hospital’s process for
will ensure trends and root causes can confirming patient’s admission, fasting
be identified and targeted and preparation details to ensure they
arrive on-time and prepared?
 To be reviewed alongside average late
starts and delay reasons to determine the  Are staff routinely recording reasons for
extent by which lists are starting late and late starts to enable identification of root
what actions may be required to address causes and trends?
Average
 To be reviewed alongside the starting on  Are rosters suitably aligned to enable the
time and elective delays metric to required preoperative duties to be safely
Late Start
Minutes understand the frequency of late starts undertaken prior to the required session
and reasons for delays to first cases start time?

3.5.6 Changeover
Changeover, or turnover, time refers to the time from when one patient exits the OR to the next patient
entering the OR within the same session. This time is necessary for cleaning the theatre, removing
unsterilised equipment and replacing with clean equipment. An efficient changeover is within the control
of a hospital and is reliant on staff being available, equipment being ready and the next patient being
appropriately prepared.
Changeover time is dependent on a number of factors including:

 Infrastructure and layout of the theatre environment (e.g. access to equipment, distance between
holding bay to operating theatre)
 Capability for parallel processing
 Communication processes (e.g. push / pull approach to notify next case ready to enter or exit OR)
 Emergency cases in elective sessions
 Case mix and / or anaesthetic complexity
Furthermore, delays during changeover can be the result of a number of factors including:
 The next patient not being ready for surgery
 Anaesthetic staff accompanying the previous patient to recovery and therefore being unable to
commence work on the next patient
 Consent or anaesthetic assessment on admission
 Theatre staff requiring breaks
 A full recovery ward
 Waiting for availability of an orderly to collect a patient from theatre
To reduce the time taken between cases, it is recommended that HHSs, where possible:
 Review the theatre layout, environment and storage through the use of methodologies and programs
such as LEAN Thinking or TPOT (for example)
 Utilise parallel processing
 Clearly define communication protocols between admissions, orderlies, theatres, recovery and wards
to alert staff of incoming and outgoing patient flows
 Schedule similar / same cases consecutively to reduce the time required for equipment changeover
e.g. book laparoscopic cases together
 Ensure high turnover lists with cases requiring the same equipment are booked to enable sufficient
time for sterilisation and reprocessing without delay e.g. avoid booking an all-day endoscopy list with
all colonoscopy cases where there is insufficient equipment to complete the list without a delay for
sterilising
 Record all protracted changeover times in the operating room management information system as a
delay to allow hospitals to understand the reasons for delays and thus make improvements

Where hospitals don’t have access to dedicated emergency sessions, average changeover times may
be increased due to the unplanned nature of emergency cases which may interrupt and delay elective
lists. Generally, changeover times between emergency cases will be significantly longer than that of
elective cases.
When reviewing average changeover time for booking and estimation purposes, consideration also
needs to be given to case mix and may be beneficial to review at a specialty and / or sub-specialty level
given the variation that will exist.
Additionally, where patients are treated in a different theatre to that which they were booked, despite
being treated by the same team, the time for that case will be reflected as an extended changeover for
that session. The below diagram highlights this situation further:
Figure 6 Protracted changeover time example

 Used to inform bookings processes to enable

a more accurate booking estimate
 Case mix should be considered when
comparing average changeover times as
more complex cases may require longer set-
up and anaesthetic preparation
 Where patients are treated in a different
theatre to that which they were booked,  Are patient bookings being allocated to
despite being treated by the same team, the the most appropriate theatre?
time for that case will be reflected as an  How are meal breaks managed and
extended changeover for that session recorded?
Average
 Average changeover time for hospitals  Is the physical layout of the theatre
running all day lists without meal relief will be conducive to minimising changeover
Changeover
Time impacted as the time taken for meal breaks times?
will reflect as changeover time  Are protracted changeover times
 Changeover time will typically be higher clinically justifiable due to complex
where emergency cases are completed in anaesthetics being undertaken outside
elective sessions of the operating theatre?
 Hospitals without anaesthetic bays may wish
to target a shorter average turnover time,
given that anaesthetic duties will be
completed inside the operating theatre
 It is recommended that hospitals report on
this measure with the option to drill down to
specialty / sub-specialty level and / or
 Is notification of emergency cases

 In the context of changeover times, this communicated to the Floor
should be considered as the changeover time Coordinator in a timely manner?
Emergency
for emergency cases is generally longer than  Are emergency cases entered onto the
that for electives emergency board immediately to
Cases in
Elective  Where demand for emergency surgery is ensure decision makers have up-to-
Sessions frequently occupying elective sessions, a date information to optimise theatre
review of emergency session allocations may access and use?
be necessary as part of a review of the  What is the process for notifying of any
master theatre template specific equipment or resource
requirements for emergency cases?

3.5.7 Finishing on Time
Finishing late (or early) can be the result of a range of factors including poor planning, unnecessary
delays, inefficiencies on the day of surgery, cancellations on the day of surgery, surgical and anaesthetic
complications and / or a misalignment between booking processes and actual operating time (e.g.
overbooked or under-booked lists).
Late finishes not only increase the likelihood of cancellations on the day of surgery but are also costly
(due to staff overtime) and contribute to staff dissatisfaction, particularly if occurring on a regular basis.
Similarly, early finishes are also costly due to the potential for wasted time which has been staffed and
resourced and could have been used to complete another case.
HHSs should adopt a balanced approach to managing overruns and underruns to ensure unnecessary
cancellations and poor utilisation is minimised. The benefit of running overtime versus finishing early
should be reasonably considered and a flexible approach adopted where either overruns and / or
underruns are not occurring on a routine basis.
To support this, it is recommended that:
 HHSs implement a clear procedure for the escalation and approval of overruns and cancellations on
the day of surgery. The focus should be on proactively identifying potential overruns or cancellations
early to enable a timely, balanced and well-informed decision to be made
 When implementing an escalation procedure, the following factors should be considered when
making decisions regarding overruns and cancellations:
- Clinical urgency of the patient and / or whether the cancellation will result in a breach of clinically
recommended waiting times
- The patient’s demographics and place of residence
- Any previous hospital-initiated cancellations of the patient
Staff availability and willingness to work late and for how long
- Budget constraints in terms of overtime expenditure
- Other individual patient considerations
 HHSs should endeavour to routinely monitor overruns and underruns through a considered approach
to the range of metrics described earlier in the guideline so that any root causes can be identified and
managed
 HHS’s have a process for early identification of training and education sessions (e.g. Registrar led
lists) to ensure they are booked appropriately and run to schedule to minimise late finishes
 HHS’s consider the use of standby patients for high-cancellation lists to enable last minute
cancellations to be replaced to reduce early finishes (more information below)

3.5.8 Standby Lists / Patients
The purpose of standby lists and standby patients is to allow hospitals to fill vacancies on theatre lists at
short notice as a result of last minute cancellations. This may be within 24 hours where appropriate.
Principles:
 Patients have agreed to be contacted at short notice and confirmed their availability
 Patients have agreed to the maximum timeframe within which they can be available at short notice
(e.g. within 24 hours, 48 hours, 72 hours)
 Patients have undergone necessary pre-op assessment and are suitable to be standby patients
 Selected patients do not require any specific equipment or preparation that would preclude surgery
being undertaken at short notice
 Depending on timeframe to surgery, typically only minor, day-case patients are suitable
 Where a patient declines an offer of surgery for a standby booking, it should not be counted as a
cancellation / decline of an offer of surgery under the elective surgery implementation standard’s ‘two-
strike’ guideline
 Clear processes are in place to communicate last minute changes to theatre lists to all relevant
stakeholders including surgeon, anaesthetist and theatre

 Overruns can be the result of a range

of factors as below and thus this
measure should be reviewed alongside  What is the hospital’s policy and escalation
other associated metrics: procedure for anticipated overruns?
- Emergency cases treated in elective  Is sufficient time being allowed for cases /
sessions lists used for education and training?
Finishing On - Late starts  How is notification of cases / lists requiring
Time – - Delays and prolonged changeover additional time for education and training
times communicated to bookings?
Overruns
- Lists not booked appropriately  Are there any trends for lists running
(Late
(overbooked) overtime – either related to specialty,
Finishes)
 If using this metric in the context of staffing, session, theatre, day of week that
overtime, note that this also includes could be further explored if the root cause
morning sessions which finish late is unknown?
 It is recommended that hospitals report  Is sufficient time being allowed for

on this measure by session type changeovers?
(morning, afternoon and all day
sessions)
 Underruns should be reviewed

alongside other associated metrics as
they can be the result of a range of  What is the hospital’s process for standby
factors as below: patients to ensure last minute
- Lack of demand to fill sessions, cancellations can be replaced?
including insufficient short cases for  Where demand is insufficient to fill an
Finishing On gap-fillers available session, what options are
Time – available to ensure this time is used? E.g.
- Cancellations on the day of surgery /
could another surgeon or specialty use this
within 24 hours
Underruns time?
- Lists not booked appropriately
 Is the allowed changeover time between
(Early (underbooked)
Finishes) cases appropriate?
- Early starts
 What is the hospital’s policy and procedure
 Depending on the frequency, HHSs for cancellations on the day of surgery and
may elect to review early finishes does it promote a reasonable approach to
alongside early starts to determine if decision making regarding whether to
session times are aligned to activity overrun or cancel and underrun?
and rosters

 Dependent on case mix, HHSs may
elect to monitor this metric against a
different threshold (e.g. 30 minutes or
60 minutes) based on what is
reasonable in terms of impacts on
throughput e.g. an endoscopy list may
elect to monitor against a 30 minute
threshold as another case could be
booked which is operationally
meaningful.
3.5.9 Minimising Delays

Delays can occur during each stage of the perioperative pathway and can be the result of patient and /
or hospital related reasons. Delays contribute to poor utilisation by resulting in late starts, prolonged
changeovers, late finishes, bottlenecks in patient flow and day of surgery cancellations.
Reasons for delays in various stages of the perioperative pathway can include:
 Priority emergency cases
 Equipment failure
 Equipment / prosthetics / organ unavailable
 Inappropriate booking / failure to notify regarding special requirements
 Changes to list order on the day of surgery
 Staff unavailable (surgeon, anaesthetist, nursing, recovery, orderly, support services)
 Staff arriving late
 Awaiting pathology results
 Incomplete documentation (e.g. consent)
 Prior case ran over
 Patient arrived late
 Patient not ready for transport (to / from ward, trolley availability, lift delay)
 Patient’s condition requires further preparation
 Radiology delays / unavailability
 Recovery full and unable to accept patients
 Staff training, resulting in extensive case time
 Set-up and sterilisation delays
 Disaster Plan activity e.g. Fire alarm activation
Recommendations described in previous sections of the guideline relating to theatre planning, starting
on time, changeover time and finishing on time are all consistent with minimising delays.

However, one of the main challenges with managing delays is access to reliable data as a result of
limited and inconsistent data entry. This is typically because staff working in theatre may be unaware
that there has been a delay, are unsure of the root cause of the delay and / or are unaware of the need
to record the delay reasons. Thus, it is recommended that HHSs:
 Educate theatre staff to ensure delay reasons for all delays (and not just late starts) are routinely
recorded by entry into the operating room management system
 Monitor and audit delays to ensure the application of delay codes is consistent and accurate and the
use of free-text reasons is minimised
 The effectiveness of this measure is

dependent on consistent and accurate
data entry when there are delays.
Depending on system limitations, this may  How is the hospital ensuring delay
require staff to manually identify and reasons are routinely identified and
record all delays where auto-prompts are recorded?
not available  Are there any noticeable trends in time
Elective Delay
Minutes  It is recommended that all delays be such as time of day and / or day of
assigned a delay reason code rather than week that may reflect a wider issue?
the use of free text to enable aggregate  Are delays primarily the result of late
reporting starts or protracted time between cases
 It is recommended that HHSs report on (changeover time)
delays by delay reason, time of day and
day of week to assist with identifying root
causes
Average  Are bottlenecks in recovery causing

 Patient flow indicator to ensure bed blocks delays for the next patient to access
Recovery
in recovery are not delaying theatres theatre?
Delay
between  Hospitals should ensure appropriate  What is the procedure for escalating
Ready for recovery delay reason codes are entered and managing bed block in Recovery?
Discharge to to enable identification of root causes for
delays  Is the rostering of orderly staff aligned
Discharge
to peak periods of activity?

3.5.10 Cancellations
Reducing cancellation rates on the day of surgery will assist with minimising lists that finish early and
therefore reduce wasted time in the operating theatre. Cancellations can be the result of patient and / or
hospital initiated reasons, a number of which may be avoided through good practice.
Understanding the reasons for cancellations is important as they can either be an indicator of
inefficiencies or contribute to inefficiencies.
Reducing hospital-initiated cancellations is also vital for ensuring a positive patient experience as last-
minute cancellations can be inconvenient, distressing and costly.
Common cancellation reasons and strategies for minimising cancellation rates include:
Patient Initiated Cancellation Preventative Strategies

Reason
Patient cancelled booking  Confirmation processes including on the day before surgery
 Relevant pre-admission education to optimise condition prior to

surgery
 Education regarding the need to contact the hospital if change in
Unfit due to condition
condition so that cancellations can be replaced
 Appropriate pre-assessment and triage to ensure readiness and
suitability for surgery
 Confirmation process day before surgery reinforcing admission and

Unfit due to patient’s preparation fasting details
 Education materials provided regarding pre-op preparation
 Staggered admission times

Patient did not wait  Regular communication to patients regarding expected waiting times
on day of surgery
Failed to attend preadmission clinic  Preadmission confirmation process
Failed to attend day of surgery  Confirmation process day before surgery
No longer requires treatment  Ensure early pre-assessment clinic

 Ensure consent is complete prior to placement on waiting list
Patient requested to be removed  Regular audit of waiting lists
 Regular audit of waiting lists

Patient could not be located  Ensure registration details are updated at time of referral to waiting list
 Ensure patients are informed of the need to update details if relocating
Treated elsewhere
Deceased prior to elective surgery

Hospital Initiated Cancellation
Preventative Strategies
Reason
Consultant cancelled booking  Process where review of patients is undertaken prior to booking with
another surgeon
Surgeon elected not to perform case
 Appropriate pre-assessment and triage to ensure readiness and
suitability for surgery
Consultant removed patient  Ensure early pre-assessment clinic
 Agree and set bed booking quota

No beds available
 Review seasonal bed demands across the year to identify peak
periods and adjust bed cap accordingly
No ICU beds available  Daily bed management meetings / communication with bed managers
 Early identification of bed requirements (e.g. on booking form)
No operating theatre time  Escalation and approval process for cancellations day of surgery
Surgeon unavailable - on leave  Business rules regarding leave planning and notification
Anaesthetist unavailable – on leave  Confirm staff rosters at theatre scheduling meetings
Surgeon unavailable - insufficient staff  Regular roster reviews to ensure sufficient staff to cover planned
sessions
Anaesthetist unavailable – insufficient  Rostering contingencies in place for locum and / or agency staff as
staff required and at short notice
Insufficient staff - Nursing  Review of staffing patterns including overtime, sick leave, fatigue leave
Insufficient staff - Other etc.
Surgeon unavailable - urgent case

 Dedicated Emergency board coordinator and clear process for the
Anaesthetist unavailable - urgent case referral and booking of emergency cases
Equipment failure/unavailable  Processes in place for routine checks and maintenance
 Partially book lists 4 – 6 weeks ahead, allowing room for anticipated

Priority elective Category 1 or priority cases
 Refer to figure 3: Elective Surgery Planning
 Dedicated floor coordinator roles across nursing, surgical and

anaesthetic teams to enable collaborative planning of emergency
surgery
Emergency case
 Review emergency demand and the need for new / multiple dedicated
emergency or trauma theatres as per the Queensland Health
Emergency Surgery Access Guideline

Other Cancellation Reasons
Removed due to audit/policy
Case brought forward
Transferred to other hospital

 N/A – unlikely to be reasons for cancellation on the day
Transferred to a non-QH facility
of surgery and / or not preventable e.g. Natural Disaster
Treated as Emergency
Data Entry Error
Natural Disaster

 It is recommended that HHSs report on

 Does the hospital have a robust and
cancellations by cancellation reason
effective auditing process to ensure
code to review the proportion of
patient details and waiting lists remain up-
hospital and preventable patient-
to-date?
initiated cancellations
 Does the hospital enforce FTA,
 Cancellations on day of surgery can be
cancellation and Not Ready for Surgery
the result of a range of factors
(NRFS) policies as per the Elective
including:
Surgery Implementation Standard?
- Patient cancelled booking
 Is the hospital’s admission times protocol
- Patient unfit due to condition or appropriate and reasonable in terms of
preparation patient waiting times?
- Patient did not wait  What is the hospital’s process for
- Patient failed to attend (FTA) day of confirming surgery to prevent last-minute
surgery cancellations and is it effective?
Elective - Consultant cancelled booking  Does the hospital have a ‘standby’ waiting
Cancellations on list to replace last minute cancellations?
- Surgeon elected not to perform
Day of Surgery case  How are lists reviewed and ordered to
ensure availability of equipment/
- No beds or ICU beds available
prosthesis/ resources (including reps)?
- No operating theatre time due to list
 Is the pre-op education material and
overruns
information provided to patients adequate
- Staff unavailable - urgent leave and appropriate?
- Staff unavailable - urgent case  What is the hospital’s policy / procedure
- Equipment failure/unavailable on elective surgery bed quotas?
- Natural Disaster  Does the hospital have a cap on bed
bookings which considers seasonal
- Patient cancelled - priority elective
trends?
- Patient cancelled – emergency
 What is the escalation and management
case
procedure for anticipated list overruns?
 It is also recommend that HHSs have a
 How are emergency cases requiring
local escalation policy for approving
treatment in an elective list managed?
cancellations on day of surgery.

3.5.11 Comparative Elective Theatre Utilisation
The significance of understanding that there is no practical and easy to use single indicator that reliably
summarises overall theatre efficiency is particularly relevant for Comparative Elective Theatre Utilisation,
as well as traditional measures of reporting theatre utilisation. It is important to highlight that these
measures are not a reflection of a HHSs efficiency or productivity.
To understand the rationale for revising the theatre utilisation metric, it is necessary to acknowledge that
the historical measure of theatre utilisation (i.e. Sum of Wheels-in to Wheels-out as a percentage of
available time) is fundamentally flawed as it does not enable transparency and comparability of a range
of factors that vary between hospitals such as caseload, case mix and anaesthetic room availability. For
example:
 It does not give consideration to the number of changeovers within a session, thus the more cases a
theatre does, the lower a theatre’s utilisation e.g. a morning list is 240 minutes. If 2 cases with a 20
minute changeover are completed the utilisation at best will be 92%. The next theatre is a highly
efficient team who do 8 cases with 10 minute changeovers. Their utilisation at best is only 71%.
 It does not give consideration to case mix and sessions where more complex procedures are frequent
and thus longer changeovers are required, resulting in lower utilisation.
 It discriminates between hospitals with anaesthetic rooms e.g. if an anaesthetic room and staff are
available to permit the commencement of anaesthetic care of one patient before the completion of
anaesthetic care of another patient for the same operating theatre, then the utilisation within the OR
would be less than those hospitals where anaesthetic preparation is conducted In the OR.
Thus the revised comparative utilisation measure has been adopted to enable a better measure of
utilisation as:
 It does not discriminate between case mix, and
 It enables better visibility of inefficiency without being distorted by different list lengths and
compositions
However, similar to the limitations of other utilisation measures, this new metric still only represents the
amount of time a planned operating theatre session is occupied by a patient with consideration given to
the necessary changeover time required to turnaround all cases. This measure does not take into
account effective rostering and allocation of staff which is crucial when considering efficiency, nor does it
reflect the productivity of the time used.
For example: Team 1 may perform one Cholecystectomy in a session, taking the whole session to
complete and incurring an overrun, yet reports high utilisation; however Team 2 performs three
Cholecystectomies in the same session, finishes early yet reports lower utilisation due to the number of
changeovers and an early finish, despite being more productive than Team 1.

Other considerations for the use of this measure include:
 Hospitals running all day lists without meal relief need to acknowledge that comparative utilisation will
be unchanged but the time taken for meal breaks will be reflected by protracted average changeover
times
 This measure only includes sessions that were open. Hence, if considering overall utilisation of
available / planned sessions, the measure for unplanned session closures should be reviewed. For
example: Five theatre sessions may be planned and available for use. However only one is actually
used. The elective theatre utilisation for that one theatre could be 95% yet unplanned session
closures are 80%, thus broadly inefficient
 It should be noted that the 15 minute nominal changeover time is the benchmark for hospitals that
conduct the anaesthetic preparation in an anaesthetic room. Facilities without anaesthetic rooms may
wish to adjust the nominal changeover time to better reflect the time between a patient exiting the
operating room and the next patient entering
3.5.12 Cost per Weighted Activity Unit by Diagnosis Related Group

As referenced earlier in this document, in an Activity-Based Funding (ABF) environment, a better
measure of technical efficiency for surgical services is the cost per Weighted Activity Unit (WAU)
delivered by the service. However, limitations in how both costing and activity are able to be attributed
solely to the operating theatres means that this measure is primarily useful for monitoring the efficiency
of the whole of services, and the activity delivered across all Diagnosis Related Groups (DRGs). This is
because the measure of WAU’s includes costs associated with all aspects of care and is not exclusive to
operating theatre expenses.
To provide a more practical use for this metric, it is recommended that HHS’s limit reporting to a
reasonable and manageable number of DRG’s such as the top 20 highest cost variances to national
average for that DRG for the HHS. HHS’s may also elect to report on DRG’s by Service Related Groups
(SRG) to drill down to a specialty level, although it is noted that the mapping between Hospital Specialty
Units and SRG’s may not be 1:1. HHSs should look to compare any trends across high cost DRG’s in
accordance with the cost drivers outlined in section 3.6. This measure would not be applicable to HHSs
that are block funded.
Furthermore, any measures based on WAU comparisons are influenced by a hospital’s case mix, the
degree of training the hospital is required to provide and the general speed of staff thus benchmarking
should be undertaken with similar hospitals.
Depending on the HHS’s level of maturity in terms of costing and coding, this measure should only be
used indicatively and as a general reference for overall surgical efficiency.
3.5.13 Elective Surgery Patients Treated within Clinically Recommended

Time by Category
This measure has been referenced in the guideline as it is currently the primary Key Performance
Indicator in HHS Service Agreements relating to elective surgery. It represents one of the core principles
for improving theatre efficiency, to ensure patients have safe and timely access to elective surgery at all
Queensland Public Hospitals.

3.6 Managing High Cost Drivers
Overall costs of an operating theatre include both fixed and variable costs as well as direct and indirect
costs, with the key elements contributing to the total cost of operating theatres broadly represented
below:
Fixed (Indirect)
Variable (Direct)
Costs that remain relatively constant
Costs that vary relative to the volume of activity
irrespective of variations
For example: For example:

• Infrastructure • Staff wages / salaries
• Capital equipment • Overtime and other non-standard wages
• Depreciation • Consumables
• Overheads • Disposable equipment
• Licences and levies • Prosthetics
• Stationery and other supplies
• Communications expenses
Hospitals can control variable costs by managing the use of their theatres, effective purchasing and
efficient rostering practices. It is through understanding the operating theatre’s high cost drivers (i.e. any
activity that can significantly impact total costs) that HHSs may be able to reduce such variable costs.
In order to monitor, review and act on cost drivers to reduce expenditure, it is equally important that
complete and quality data is readily available. The role of a dedicated data manager should be
considered to ensure measuring and reporting is accurate and reliable.
The following table, derived from the NSW Agency for Clinical Innovation as evidenced from the
University of Wollongong Literature Review, outlines the common cost drivers for operating theatres:
Figure 7 OT Cost Drivers
Cost driver Detail
Anaesthetic drugs The type of anaesthetic used for the procedure will drive both the costs of
anaesthetic staff and equipment
Blood products The volume and type of blood products used during a procedure
Delays and cancellations On the day of surgery can result in theatre downtime, unless other surgical cases
can be scheduled at short notice
Diagnostic services Pathology and imaging services that are provided during the procedure

Duration of procedure Time is a key predictor of cost in operating theatres
The range of reusable and disposable instruments, the surgical solution and the pick
Medical and surgical lists required by surgeons have a significant bearing on the procedure cost. Although
supplies some expensive consumables may be associated with a reduction in length of stay,
the increased OT cost may result in an overall decrease in the episode cost
Undertaking minimally invasive procedures that do not require the infrastructure of

Models of care an OT in a specialised procedure suite or other non- surgical spaces such as
intensive care or clinics will result in different costs
The type of prosthesis used significantly influences some procedure costs. The
Prostheses
negotiation of contracts with suppliers may also be of interest
One of the most significant cost drivers in the OT is the number, seniority and skill
Staffing intensity mix of the staff in attendance. The complexity of the procedure and/or the patient
morbidities will drive the required staffing intensity
Surgical technique One of the biggest influences on duration is surgical technique and behaviour
Less invasive surgical procedures using newly available technologies are the most
Technology/Equipment costly in the operating theatre but are associated with a reduction in length of stay
and potentially increasing OT costs but decreasing total episode costs
The time taken to set up between a finished case and the next case will influence the
Turnover time
throughput and therefore the cost per minute
Wastage The amount of wastage of drugs and clinical supplies will also influence the costs
Source: NSW Agency for Clinical Innovation (2014)
4. Aboriginal and Torres Strait Islander Considerations

Queensland public hospital services and staff recognise and commit to the respect, understanding and
application of Aboriginal and Torres Strait Islander cultural values, principles, differences and needs
when caring for Aboriginal or Torres Strait Islander patients.
Each individual HHS is responsible for achieving successful provision of culturally appropriate surgical
services to and with Aboriginal and Torres Strait Islander individuals and their communities within the
respective HHS catchment.
Equally, the respect and acknowledgement extended to Aboriginal and Torres Strait Islander people will
be extended to all participants, irrespective of ethnic background or membership of community group.

5. Abbreviations
ABF Activity Based Funding
BMI Body Mass Index
DRG Diagnosis Related Group
FTA Failed to Attend
FY Financial Year
HHS Hospital and Health Service
ICU Intensive Care Unit
KPI Key Performance Indicator
NRFS Not Ready for Surgery
NESUCG National Elective Surgery Urgency Categorisation Guideline
OR Operating Room
QAO Queensland Audit Office
SRG Service Related Group
TPOT The Productive Operating Theatre
WAU Weighted Activity Unit
6. References
Supporting Documents
 Elective Surgery Implementation Standard – Queensland Health
 Emergency Surgery Access Guideline – Queensland Health
 Queensland Audit Office – Queensland public hospital operating theatre efficiency: Volume one,
Report 2015-16
 Queensland Health Clinical Services Capability Framework v3.2, 2014
 Queensland Health – Guide to Informed Decision-making in Healthcare
 State of Queensland (Queensland Health) - My health, Queensland’s future: Advancing health 2026
 The Australian Institute of Health and Welfare (AIHW) – Australian hospital peer groups
Related Documents
 Agency for Clinical Innovation 2014, Operating Theatre Efficiency Guidelines: A guide to the efficient
management of operating theatres in New South Wales hospitals, Agency for Clinical Innovation,
Chatswood
 Audit Office of New South Wales, 2013, New South Wales Auditor-General’s report performance
audit: Managing operating theatre efficiency for elective surgery, Audit Office of New South Wales,
Sydney

 Metro North Hospital and Health Service 2015, MNHHS operating theatre guideline – defining Metro
North theatre performance, Metro North Hospital and Health Service, Herston
 National Health Service (n.d), Step guide to improving operating theatre performance, National Health
Service, United Kingdom
 National Health Service, 2007, Theatre operating list session scheduling policy, National Health
Service, Nottingham
 National Health Service, 2007, Operating theatre list policy, National Health Service, Bath
 Pandit, J, Stubbs, D, Pandit, M 2009, ‘Measuring the quantitative performance of surgical operating
lists: theoretical modelling of ‘productive potential’ and ‘efficiency’’, Anaesthesia Journal of the
Association of Anaesthetists of Great Britain and Ireland, vol. 64, PP 473 – 486
 Stapleton P., Henderson A., Creedy D.K. et al. (2007) Boosting morale and improving performance in
the nursing setting. Journal of Nursing Management 15 (8), 811–816.
7. Appendices
Appendix A: Theatre Efficiency Measures and Metrics

Appendix B: Definitions
Appendix C: Management Committee Membership
Appendix D: Operating Theatre Efficiency Performance Indicator Attribute Sheets

Appendix A: Theatre Efficiency Measures and Metrics
As described in Section 2 of the guideline, where measures and KPI’s have been described, statewide
targets will not be set for the first year of implementation. The approach to establishing targets and
benchmarks will follow a progressive, evidence-based approach whereby collection for the first 12
months will focus on assessing relative performance to enable the Department to understand the level of
variation. This will ensure appropriate targets are set in the future with the expectation that these will be
applied as stepped improvement targets from Year 2 of the implementation plan.
The following outlines the range of measures and metrics as described in the Theatre Efficiency
Guideline, listed in alphabetical order for ease of reference.
Alignment with National Elective Surgery Urgency Categorisation Guideline ……………. 55

Average Changeover Time……………………………………………………………………... 56
Average Elective Pre-Procedure Anaesthetic Care Start Time…………………………….. 57
Average Late Start Minutes…………………………………………………………………….. 58
Average Recovery Delay Between Ready for Discharge to Discharge…………………… 59
Booked versus Actual Time…………………………………………………………………….. 60
Comparative Elective Theatre Utilisation……………………………………………………… 61
Cost per Weighted Activity Unit (QWAU)……………………………………………………… 62
Elective Cancellations on Day of Surgery…………………………………………………….. 63
Elective Delay Minutes………………………………………………………………………….. 64
Elective Surgery Long Wait Patients………………………………………………………….. 65
Elective Surgery Treated Within Clinically Recommended Time by Category……………. 66
Emergency Cases in Elective Sessions………………………………………………………. 67
Emergency Theatre Occupancy……………………………………………………………….. 68
Finishing On Time – Overruns (Late Finishes)………………………………………………. 69
Finishing On Time – Underruns (Early Finishes)……………………………………………. 70
Net Additions to Waiting List……………………………………………………………………. 71
Out of Session Emergency Case Time………………………………………………………... 72
Starting on Time…………………………………………………………………………………. 73
Total Patients Treated………………………………………………………………………….. 74
Treat In Turn……………………………………………………………………………………… 75
Unplanned Session Closures…………………………………………………………………... 76

Alignment with National Elective Surgery Urgency Categorisation Guideline (NESUCG)
Percentage of patients whose assigned clinical urgency category aligns with

Description that described in the National Elective Surgery Urgency Categorisation
Guideline
Denominator: The count of patients whose procedure code (ACHI code) maps to an
Calculation ACHI code listed in the NESUCG
Numerator: of those patients whose procedure code maps to an ACHI code listed in
the NESUCG, the count of those patients whose assigned category is the same as that
listed in the NESUCG
Formula: (Numerator ÷ Denominator) x 100%
Procedures listed within the NESUCG

Inclusions Elective cases
Procedures excluded from the NESUCG

Exclusions Emergency cases
Year 1: Local target and assessment of relative performance

Goal
Year 2 onwards: Stepped improvement targets to be established
Associated
Indicators  Elective Surgery Long Wait Patients
 Elective Surgery Treated Within Clinically Recommended Time by Category

Average Changeover Time
Average time between all cases treated in elective sessions measured from
Description
previous case ‘Out OR’ to next case ‘In OR’
Sum of [‘Out OR’ - ‘In OR’] for all cases treated in an elective session
Calculation
Number of patients treated – Number of sessions
Elective and Emergency cases performed in elective sessions only

Inclusions
Open sessions
Planned closures (A session closed on or after 48 hours prior to the session start time)
Exclusions
Unplanned closures (A session closed within 48 hours of the session start time)

Goal
 Comparative Elective Theatre Utilisation

Associated  Booked versus Actual Time
Indicators  Elective Delays
 Emergency Cases in Elective Sessions

Average Elective Pre-Procedure Anaesthetic Care Start Time
Average time from ‘In Anaesthetic’ to ‘Procedure Start’ for the first case of an
Description
elective morning or all day session.
st
Sum (‘In Anaesthetic’ to ‘Procedure Start’) for 1 cases of an elective morning or all day session
Calculation st
Number of 1 cases in elective sessions
Elective cases in elective sessions

Inclusions 1st cases within morning only sessions
1st cases within all day sessions
1st cases within afternoon only sessions

Exclusions
Sessions where the 1st case is an Emergency case

Goal
 Booked versus Actual Time

Associated  Starting on Time
Indicators  Average Late Start Minutes

Average Late Start Minutes
Of those lists starting late, the average time (minutes) by which they started late
Description A late start is defined as any session where the first case In OR time is after the
scheduled session start time
Sum [In OR - Session Start] for sessions starting late

Calculation
Number of sessions starting late
Elective and Emergency cases in elective sessions, including morning, afternoon

Inclusions and all-day sessions
Open sessions
Planned closures (A session closed on or earlier than 48 hours prior to the session start time)
Exclusions

Goal
 Starting on time
Associated
 Average Elective Pre-Procedure Anaesthetic Care Time
Indicators
 Elective Delays

Average Recovery Delay Between Ready for Discharge to Discharge
Average time taken between when an elective patient is ready for discharge to
Description
when they are actually discharged
Discharge time – Ready for Discharge time for each patient

Calculation
Number of Discharges
Emergency cases
Exclusions
Patients that bypass recovery

Goal
Associated  Finishing on Time – overruns


Booked versus Actual Time
Comparison between booked total case time (how the session was planned to be
used) and actual total case time (how the session was actually used)
Description
Includes late and early starts and finishes and changeover times
[Last Case Out OR] – [First Case In OR] - Total booked elective minutes x 100%
Calculation
Total planned session minutes Total planned session minutes
Open sessions
Inclusions
Exclusions

Goal

Associated  Finishing On Time – Overruns (Late Finishes)
Indicators  Finishing On Time – Underruns (Early Finishes)

Comparative Elective Theatre Utilisation
A comparative measure of overall theatre utilisation that considers the total time the
operating theatre is actually occupied by a patient in the OR, and the necessary time
for changeover (by applying a nominal changeover time) as a percentage of the planned
Description time for elective sessions.
The occupied ‘In OR time’ is measured according to the fundamental ‘Wheels in, Wheels
Out’ measure.
The nominal changeover time is set at 15 minutes.

{[Sum (In OR to Out OR) for all cases] + [(Number cases – 1) x nominal changeover time]} X 100%
Sum of Planned Elective Session Time
Calculation  If the first case In OR time is prior to session start time, then the session start time
is to be used as the In OR time
 If the last case out OR time is after the sessions end time, then the session end
time is to be used as the out OR time
Elective and Emergency cases performed in elective sessions Open

Inclusions sessions
Late starts
Early finishes
Emergency and Trauma Sessions

Exclusions Planned closures (A session closed on or earlier than 48 hours prior to the session start time)

Goal
 Elective session utilisation

 Booked versus Actual Time  Average Changeover Time
 Starting on Time & Average Late Start  Elective Delays
Associated Minutes  Elective Cancellations on Day of Surgery
Indicators  Finishing on Time – Late Finishes &  Emergency cases in elective sessions
Early Finishes

Cost per Weighted Activity Unit (QWAU)
Cost per Weighted Activity Unit (QWAU) by surgical diagnosis related groups
Description
(DRG)
For each patient separation with theatre utilisation:
Calculation Sum of the total cost (excluding depreciation and patient travel)__
Sum of those same separation’s Queensland Weighted Activity Unit
In accordance with the National Hospital Costing Standards, all costs associated with
Inclusions the patient treatment are to be attributed to the episodes of care, derived by clinical
and administrative information systems, based on each departmental review of
relative value units for the hospital identified intermediate products
Depreciation and patient travel costs are to be excluded from the numerator sum of
Exclusions total costs
HHS’s should utilise the National Benchmarking Portal available through System
Goal Performance Reporting (SPR) to compare their Cost per WAU by DRG nationally and
identify variances to inform targeted improvements
Associated
Indicators All

Elective Cancellations on Day of Surgery
Percentage of all elective patients cancelled on the day of surgery for both
Description
hospital and patient initiated reasons by cancellation reason code.
It is recommended that hospitals report separately on hospital initiated and

preventable patient initiated cancellations from all other cancellation reasons
Total number of patients cancelled day of surgery_ x 100%

Calculation Total number of patients booked to be treated on day
Day of surgery = any patient cancelled after 00:00 hours on the day of surgery

Goal
NB: Refer to Operating Theatre Efficiency Proposed Performance Indicator

Attribute sheet – Preventable Day of Surgery Cancellations

 Starting on Time
 Average Late Start Minutes
Associated  Finishing on Time – Overruns

Elective Delay Minutes
Total delays (in minutes) resulting from late starts (patients entering the OR after
Description the scheduled session start time) and prolonged changeover times (change over
time >15 minutes).
[Sum of all reported Late Starts] + [ Sum of all reported extended Changeovers]
Late Start: [In OR Time – Session Start Time] where In OR time > Scheduled Session
Calculation start Time
Extended changeover time: [ In OR - Out OR for previous case within the same session]
if greater than 15 minutes

Inclusions
Open sessions
Exclusions

Goal
 Starting on Time
Associated  Average Late Start Minutes
Indicators  Finishing on Time – Overruns

Elective Surgery Long Wait Patients
The percentage of patients waiting longer than the clinically recommended time
Description
for their Category 1, 2 or 3 Elective surgery
Denominator: The number of patients waiting for treatment for elective surgery
by category
Numerator: The number of patients who are waiting for treatment for elective
Calculation surgery who have been waiting greater than 30 days (≤ 30 days) if a category 1,
greater than 90 days (≤ 90 days) if a category 2, or greater than 365 days (≤ 365
days) if a category 3.
Elective cases
Inclusions Category 1, 2 and 3
Ready for Surgery and Not Ready for Surgery
Category 4, 5, 6 and 9
Outsourced patients
Goal ≤ 2% category 1 and ≤ 5% for category 2 and 3
Associated  Elective Surgery Treated Within Clinically Recommended Time by Category

Indicators  Net Additions to Waiting List

Elective Surgery Treated Within Clinically Recommended Time by Category
The percentage of patients who received elective surgery and were treated
within the clinically recommended time for their urgency category
Elective surgery patients treated are those who were registered on a surgical
waiting list as a category 1, 2 or 3, with a surgical specialty, and were removed
because they received their surgery as an elective or emergency patient.
Description
The waiting time is calculated as the difference between the date the patient was
placed on the waiting list and the date the patient was removed from the waiting
list, excluding any periods the patient was not ready for surgery and any periods
that the patient was waiting at a less urgent category than their category at
removal
Numerator: The number of patients who received elective surgery who were
treated within 30 days (≤ 30 days) if a category 1, within 90 days (≤ 90 days) if a
category 2, or within 365 days (≤ 365 days) if a category 3.
Calculation
Denominator: The number of patients who received elective surgery for each
respective category
Elective cases with a status of ‘Treated’ at the reporting hospital

Inclusions
Elective cases with a removal status of ‘Treated as Emergency’
Category 1, 2 and 3
Category 4, 5, 6 and 9
Exclusions
Outsourced patients
Goal ≥ 98% category 1 and ≥ 95% for category 2 and 3
Associated  Elective Surgery Long Wait Patients

Indicators  Net Additions to Waiting List

Emergency Cases in Elective Sessions
Description Percentage of planned elective session time occupied by emergency cases
Sum of emergency case minutes performed within an elective session x 100%

Sum of planned elective session minutes
Calculation  If the first case In OR time is prior to session start time, then the session start
time is to be used as the In OR time
 If the last case out OR time is after the sessions end time, then the session
end time is to be used as the out OR time
Inclusions Emergency cases performed in elective sessions only
Exclusions

Goal
Associated  Emergency Theatre Utilisation

Indicators  Out of Hours Emergency Cases

Emergency Theatre Occupancy
A measure of ‘In Operating Room’ use that reflects how much time the operating
theatre is occupied by a patient as a percentage of the planned time for
Description
emergency surgery sessions. This is measured according to the fundamental
‘Wheels in, Wheels Out’ measure
Sum (In OR to Out OR) for all cases within an emergency session X 100%
Sum of Planned emergency Session Time
Calculation  Changeover times are not included as occupied ‘In OR’ time
 If the first case In OR time is prior to session start time, then the session start
time is to be used as the In OR time (not applicable to 24 hr theatres)
 If the last case out OR time is after the sessions end time, then the session end
time is to be used as the out OR time (not applicable to 24 hr theatres)
Elective and Emergency cases performed in emergency and trauma sessions

Open sessions
Inclusions
Late starts
Early finishes
Exclusions

Goal
Associated  Emergency Cases in Elective Sessions

Indicators  Out of Hours Emergency Cases

Finishing On Time – Overruns (Late Finishes)
Percentage of elective sessions where the last case exits the Operating Room 30 minutes or
more after the scheduled session end time
Description
A late finish is defined as any session where the last case exits the OR greater than 30
minutes after the scheduled session end time.
Number of Elective sessions where the last case

Calculation exits the OR > 30 minutes after the scheduled session end time x 100%
Total number of planned elective sessions
Elective and Emergency cases in elective sessions, including morning, afternoon and all-day
Inclusions sessions
Open sessions
Exclusions

Goal
 Starting On Time
 Average Late Start Minutes
Associated
 Booked versus Actual Time

Finishing On Time – Underruns (Early Finishes)
Percentage of elective sessions where the last case exits the Operating Room 45
minutes or more before the scheduled session end time
Description
An early finish is defined as any session where the last case exits the OR greater
than 45 minutes before the scheduled session end time.
Number of Elective sessions where the last case

Calculation exits the OR > 45 minutes before the scheduled session end time x 100%

Open sessions
Exclusions

Goal
Associated  Booked versus Actual Time

Indicators  Elective Cancellations on Day of Surgery

Net Additions to Waiting List
The difference between the number of patients added to the elective surgery
Description
waiting list and the number of patients removed (either treated or removed)
[No. patients added to waiting list] – [No. patients treated from the waiting list]
Calculation
– [No. patients removed from the waiting list]
Elective cases
Inclusions
All Categories

Goal
 Elective Surgery Treated Within Clinically Recommended Time by Category

Associated  Elective Surgery Long Wait Patients
Indicators

Out of Session Emergency Case Time
Number of emergency case minutes performed out of session (i.e. not

Description within a planned session) as a percentage of the total emergency minutes
used by category
Sum of emergency case minutes performed out of session x 100%

Calculation
Total number of emergency case minutes used
Inclusions Emergency cases performed outside a planned elective or emergency session
Exclusions

Goal
Associated  Emergency Theatre Utilisation

Indicators  Emergency Cases in Elective Sessions

Starting On Time
Percentage of elective sessions where the first case In OR time is on or

before the scheduled session start time
Description
A late start is defined as any session where the first case In OR time is after the
scheduled session start time
Number of Elective sessions where the first case

Calculation In OR time is on or before the scheduled session start time__ x 100%

Open sessions
Exclusions

Goal
NB: Refer to Operating Theatre Efficiency Proposed Performance Indicator
Attribute sheet – Elective Operating Session On-time Starts
 Average Elective Pre-Procedure Anaesthetic Care Time

Associated  Average Late Start minutes
Indicators  Finishing On Time – Overruns (Late Finishes)
 Elective Delays

Total Patients Treated
Description Total number of patients treated by operation type (Elective or Emergency)
Count of Elective patients treated

Calculation
Count of Emergency patients treated
Inclusions Treated cases (treated at the reporting hospital)
Cancelled cases
Exclusions
Patients treated at another facility via outsourcing arrangements

Goal
Associated All indicators

Indicators

Treat In Turn
Description The percentage of Category 2 and 3 Elective Surgery patients treated in turn
As per Treat in turn calculation fact sheet located at:

Calculation
http://qheps.health.qld.gov.au/caru/nest/docs/fs-treat-in-turn.pdf
Inclusions Refer to above factsheet
Exclusions Refer to above factsheet
Goal ≥ 60%
Associated  Elective Surgery Treated Within Clinically Recommended Time by Category

 Elective Surgery Long Wait Patients
Indicators
 Net Additions to Waiting List

Unplanned Session Closures
Measure of how many planned elective sessions are closed at late

Description
notice (within 48 hours of the planned session time) over the total
number of planned elective sessions.
Total count of unplanned elective session closures x 100%

Total count of planned elective sessions (including unplanned session closures)
Calculation
A session is defined as either a morning, afternoon or all-day session

Inclusions Open sessions
Exclusions Planned closures (A session closed on or earlier than 48 hours prior to the session start time)

Goal
Associated  Comparative Elective Theatre Utilisation

Indicators  Total Patients Treated

Appendix B: Definitions
Scheduling Definitions
A theatre template is built on funded sessions and is the blueprint of recurring

Master Theatre
sessions applied to a specific week and to a specific theatre. The template must
Template contain session start and finish times. The template is not changed on a daily basis
Often referred to as a funded session. A session where all required resources have been
Planned Session financially apportioned within the current Surgical Services budget
A session closed on or after 48 hours prior to the session start time

Planned Closure This includes Public holidays
Unplanned Closure A session closed within 48 hours prior to the session start time
The normal period of time available to be allocated to a physician / surgeon / service for
surgery. Sessions, for example, can be morning only, afternoon only or all-day sessions.
Session
The actual period may vary from one facility to another but is typically 3.5 to 4 hours for
a morning or afternoon session and 7 to 8.5 hours for an all-day session
Time session is scheduled to commence. This should be the time the first case is
Session Start
planned to enter the OR
Time session is scheduled to be completed. This should be the time the last patient
Session End
is planned to exit the OR
Elective Session A session allocated for elective cases including all patients on a category 1 – 9 waiting list
Emergency Session A session allocated for emergency cases. I.e.: Category A – E patients
A session allocated for emergency cases which are primarily trauma-related
Trauma Session
I.e. Category D – E patients
Time (mins) between the completion of a case recorded by Out OR time to the
Changeover Time commencement of the next case, recorded by In OR time in a continuous session. Also
referred to as Turnaround time
Late start Any session where the first case In OR time is after the session start time
Early start Any session where the first case In OR time is prior to the session start time

Overrun Any session where the last case exits the OR either on or greater than 30 minutes
(Late Finish) after the session end time
Underrun Any session where the last case exits the OR either on or greater than 45 minutes before
(Early finish) the session end time
Referred to as any emergency surgery performed between the hours of 22:00 – 08:00 as
After Hours
described as outside standard emergency hours in the Emergency Surgery Access
Emergency
Guideline

Operating Room Time Stamps
In Suite Time Time the patient arrives in the operating suite or procedure room.
Time when an anaesthetist begins preparing the patient for an anaesthetic, (eg. IV
cannulation, eye blocks). This may occur inside or outside of the operating room.
In Anaesthetic Time
NB: Hospitals that commence anaesthetic outside the OR must ensure robust
processes are in place to communicate and record the accurate ‘In Anaesthetic’
time as this may not be visible to the staff in the OR responsible for the data entry.
Strictly interpreted as the time the patient enters the operating room.
In OR Time
Often referred to as “Wheels in” to OR.
Procedure Start The earlier time of either the specific positioning of the patient for surgery or
Time commencement of the skin preparation.
Time when all the instruments and sponge counts are completed and verified as
correct; all postoperative radiological studies to be done in the operating Theatre
or procedure room are completed; all dressings and drains are secured; and the
Procedure Finish surgeon(s)/physician(s) has completed all procedure related activities on the
Time patient.
Whilst not a data qualifier for procedure finish time, it is still mandatory that the
surgical safety checklist is completed for all patients undergoing surgery.
Time at which the patient leaves the operating room or procedure room.
Out OR Time
Often referred to as “Wheels Out” OR
Arrival in Recovery Time of patient arrival in Recovery
Ready for Transfer

Time when patient is ready to move from Stage 1 to Stage 2 Recovery
(Recovery)
Transfer from
Time the patient is transported out of the Recovery
Recovery
NB: The above key terms are non-system specific thus the time stamp descriptions have been defined
to represent the process occurring at each point of the patient journey regardless of individual system’s
naming conventions

Appendix C: Management Committee Membership
Membership of the Theatre Management teams will depend on the size and structure of each hospital
and may or may not require the existence of sub-groups responsible for operational and other issues.
The table below outlines possible membership and co-opted members as required:
Membership Theatre Management Committee Theatre Scheduling Committee
Chair Head of Operating Theatre Head of Operating Theatre
 General Manager / Operational  Heads of Operating Theatre

Manager (where applicable) - Nursing
 Heads of Operating Theatre - Medical – Surgery
- Nursing - Medical – Anaesthetics
- Medical – Surgery  Floor Coordinators
- Medical – Anaesthetics - Nursing
 Floor Coordinators - Medical – Surgery
- Nursing - Medical – Anaesthetics
- Medical – Surgery  Delegate/representative from each
Core - Medical – Anaesthetics relevant specialty (e.g.: Orthopaedics,
 Clinical Directors Gynaecology)
 Nurse/Unit Managers for:  Admissions Manager
- Theatre,  Waiting List Manager
- Day Surgery  Pre Admission Manager
- Surgical Ward  Data Manager
 Admissions Manager
 Waiting List Manager
 Pre Admission Manager
 Data Manager
 Finance Manager

 Support Service Managers
(Eg: Orderlies, supply, medical imaging, pharmacy)
 Case Manager
 Infection Control Manager
 Information Manager
 Security and Porterage Manager
Optional  Sterilisation Department Representative
 Nurse Educator
 HR Manager
 OH&S Manager
 Patient Liaison / Consumer Advisory Representatives
 Emergency Department Manager
 Bed Manager / After Hours Manager
Policy Custodian:
Executive Director, Healthcare Improvement Unit, Clinical Excellence Division
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Document Number # qh-gdl-443:2017

Operating Theatre Efficiency

Operating Theatre Efficiency – Guideline -2-

Operating Theatre Efficiency – Guideline -3-

Operating Theatre Efficiency – Guideline -4-

3.2 Understanding Theatre Efficiency

Operating Theatre Efficiency – Guideline -5-

• Starting and finishing on time

 Quality assurance and safety processes

Operating Theatre Efficiency – Guideline -6-

3.3 Operating Theatre Measures and Metrics

Operating Theatre Efficiency – Guideline -7-

3.3.2 Using Measures and Metrics

Operating Theatre Efficiency – Guideline -8-

Operating Theatre Efficiency – Guideline -9-

Further details regarding theatre governance are outlined in section 3.4.

3.3.3 Description of Measures

Table 1 Description of Measures

Measure Type Description

The percentage of how many planned elective

Operating Theatre Efficiency – Guideline - 10 -

The percentage of Category 2 and 3 Elective Surgery

The comparison between booked total case time (how

Total Patients The total number of patients treated by operation type

A comparative measure of overall theatre utilisation

Percentage of elective sessions where the first case In

Operating Theatre Efficiency – Guideline - 11 -

Elective The proportion of patients booked into elective

The average time between all cases treated in elective

Elective The percentage of all elective patients cancelled on the

Of those lists starting late, the average time (minutes)

The total delays (in minutes) resulting from late starts

Postoperative Average Recovery

Operating Theatre Efficiency – Guideline - 12 -

Emergency case minutes performed out of session (i.e.

Other metrics which may be useful for HHSs to consider include:

Operating Theatre Efficiency – Guideline - 13 -

To ensure data integrity and consistency, it is recommended that HHSs:

Operating Theatre Efficiency – Guideline - 14 -

Theatre Scheduling Committee/Team (Operational Management)

Theatre Management Committee/Team (Strategic Management)

Operating Theatre Efficiency – Guideline - 15 -

3.4.2 Roles, Responsibilities and Accountabilities

Head of Operating Theatres - Responsibilities

Operating Theatre Efficiency – Guideline - 16 -

Floor / Duty Coordinator - Responsibilities

Nursing Medical - Surgery Medical - Anaesthetics

Operating Theatre Efficiency – Guideline - 17 -

Other key roles within the context of managing theatre efficiency:

Operating Theatre Efficiency – Guideline - 18 -

Operating Theatre Efficiency – Guideline - 19 -

Operating Theatre Efficiency – Guideline - 20 -

3.5.1 Theatre Planning

Operating Theatre Efficiency – Guideline - 21 -

Figure 3 Elective Surgery Planning

Operating Theatre Efficiency – Guideline - 22 -

Operating Theatre Efficiency – Guideline - 23 -

Measure Use and Considerations Qualitative Assessment

 To be reviewed in conjunction with

 To be reviewed in conjunction with

 What are the main specialties occupying

Operating Theatre Efficiency – Guideline - 24 -

 A productivity measure to monitor